Provider Demographics
NPI:1679995039
Name:DAVIS, ELENA TRACEY (RPH)
Entity Type:Individual
Prefix:MS
First Name:ELENA
Middle Name:TRACEY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 E MCKELLIPS RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-2537
Mailing Address - Country:US
Mailing Address - Phone:480-964-9427
Mailing Address - Fax:
Practice Address - Street 1:730 E MCKELLIPS RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-2537
Practice Address - Country:US
Practice Address - Phone:480-964-9427
Practice Address - Fax:480-964-9430
Is Sole Proprietor?:No
Enumeration Date:2014-01-19
Last Update Date:2014-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS009553183500000X
PARP031136L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist