Provider Demographics
NPI:1578640652
Name:DAVIS DRUG COMPANY OF KENLY, INC.
Entity Type:Organization
Organization Name:DAVIS DRUG COMPANY OF KENLY, INC.
Other - Org Name:DAVIS DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:ELLIOT
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:919-284-2010
Mailing Address - Street 1:PO BOX 235
Mailing Address - Street 2:103 W 2ND ST.
Mailing Address - City:KENLY
Mailing Address - State:NC
Mailing Address - Zip Code:27542-0235
Mailing Address - Country:US
Mailing Address - Phone:919-284-2010
Mailing Address - Fax:919-284-2231
Practice Address - Street 1:103 W 2ND ST.
Practice Address - Street 2:
Practice Address - City:KENLY
Practice Address - State:NC
Practice Address - Zip Code:27542-0235
Practice Address - Country:US
Practice Address - Phone:919-284-2010
Practice Address - Fax:919-284-2231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC115123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0515679Medicaid
NC6797710001Medicare NSC