Provider Demographics
NPI:1659836294
Name:WILLIS, MCLISA VICTORIA DAVIS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MCLISA
Middle Name:VICTORIA DAVIS
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:MCLISA
Other - Middle Name:VICTORIA
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1916 BOXELDER ALY
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-3567
Mailing Address - Country:US
Mailing Address - Phone:615-226-6320
Mailing Address - Fax:
Practice Address - Street 1:2516 GALLATIN AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37206-3216
Practice Address - Country:US
Practice Address - Phone:615-226-6320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37256183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist