Provider Demographics
NPI:1639220684
Name:DAVIS, JERRY CARL (RPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:CARL
Last Name:DAVIS
Suffix:
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 1:1230 PINEY GROVE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:KENLY
Mailing Address - State:NC
Mailing Address - Zip Code:27542
Mailing Address - Country:US
Mailing Address - Phone:919-284-3570
Mailing Address - Fax:
Practice Address - Street 1:110 W 2ND ST
Practice Address - Street 2:
Practice Address - City:KENLY
Practice Address - State:NC
Practice Address - Zip Code:27542
Practice Address - Country:US
Practice Address - Phone:919-284-2010
Practice Address - Fax:919-284-2231
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC05124183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist