Provider Demographics
NPI:1831638725
Name:DAVIS, MIREN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MIREN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 E PARKCENTER BLVD
Mailing Address - Street 2:APT. 210
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6684
Mailing Address - Country:US
Mailing Address - Phone:208-999-2900
Mailing Address - Fax:
Practice Address - Street 1:509 E PARKCENTER BLVD
Practice Address - Street 2:APT 210
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6684
Practice Address - Country:US
Practice Address - Phone:208-999-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7706183500000X
VA0202209403183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist