Provider Demographics
NPI:1790388874
Name:DAVIS, EVAN JAMES
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:JAMES
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E ROUND GROVE RD APT 227
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3831
Mailing Address - Country:US
Mailing Address - Phone:817-455-5359
Mailing Address - Fax:
Practice Address - Street 1:1635 MARKET PL
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-7239
Practice Address - Country:US
Practice Address - Phone:214-574-4517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65769183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist