Provider Demographics
NPI:1598367823
Name:DAVIS, NICHOLAS SHANE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:SHANE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 TURF FARM RD
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-1645
Mailing Address - Country:US
Mailing Address - Phone:801-465-8726
Mailing Address - Fax:801-465-8728
Practice Address - Street 1:1052 TURF FARM RD
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1645
Practice Address - Country:US
Practice Address - Phone:801-465-8726
Practice Address - Fax:801-465-7828
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4857892-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist