Provider Demographics
NPI:1760536080
Name:DAVIS, GREG W (RPH)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:W
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:PO BOX 4446
Mailing Address - Street 2:2566 MEDIROS LN
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-4446
Mailing Address - Country:US
Mailing Address - Phone:707-350-0239
Mailing Address - Fax:
Practice Address - Street 1:2655 MEDIROS LN
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8179
Practice Address - Country:US
Practice Address - Phone:707-350-0239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist