Provider Demographics
NPI:1881023570
Name:DAVIS, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:2711 RAMS CT
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-1371
Mailing Address - Country:US
Mailing Address - Phone:804-484-0325
Mailing Address - Fax:
Practice Address - Street 1:5401 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-2629
Practice Address - Country:US
Practice Address - Phone:804-285-2975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202208401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist