Provider Demographics
NPI:1760428254
Name:MA DAVIS ENTERPRISES, LLC
Entity Type:Organization
Organization Name:MA DAVIS ENTERPRISES, LLC
Other - Org Name:NEWBERN DRUG HEALTHMART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:731-589-0206
Mailing Address - Street 1:625 W. MAIN ST.
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWBERN
Mailing Address - State:TN
Mailing Address - Zip Code:38059
Mailing Address - Country:US
Mailing Address - Phone:731-627-9573
Mailing Address - Fax:731-627-3051
Practice Address - Street 1:625 W MAIN ST.
Practice Address - Street 2:SUITE A
Practice Address - City:NEWBERN
Practice Address - State:TN
Practice Address - Zip Code:38059
Practice Address - Country:US
Practice Address - Phone:731-627-9573
Practice Address - Fax:731-627-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN332B00000X
333600000X
TN4393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454269Medicaid
2089282OtherPK
2089282OtherPK