Provider Demographics
NPI:1548427818
Name:DAVIS, CHARLES M JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:M
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 MARILYN ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-8022
Mailing Address - Country:US
Mailing Address - Phone:208-237-6993
Mailing Address - Fax:
Practice Address - Street 1:2530 MARILYN ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-8022
Practice Address - Country:US
Practice Address - Phone:208-237-6993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-4701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist