Provider Demographics
NPI:1922385590
Name:DAVIS, NICOLE R (RPH)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3307 W POLK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-4148
Mailing Address - Country:US
Mailing Address - Phone:773-722-6212
Mailing Address - Fax:
Practice Address - Street 1:2015 E 79TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-5026
Practice Address - Country:US
Practice Address - Phone:773-734-2492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051039448183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist