Provider Demographics
NPI:1538647250
Name:DAVIS, BRIAN D (RPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:BRIAN
Other - Middle Name:D
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:600 WINDING OAKS PL
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7379
Mailing Address - Country:US
Mailing Address - Phone:314-210-7121
Mailing Address - Fax:
Practice Address - Street 1:600 WINDING OAKS PL
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-7379
Practice Address - Country:US
Practice Address - Phone:314-210-7121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050041931835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2005004193OtherMO BOARD OF PHARMACY