Provider Demographics
NPI:1134403710
Name:DAVIS, TARA AILEEN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:AILEEN
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 1:4890 BARKSDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-4566
Mailing Address - Country:US
Mailing Address - Phone:318-747-4330
Mailing Address - Fax:318-746-2773
Practice Address - Street 1:4890 BARKSDALE BLVD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-4566
Practice Address - Country:US
Practice Address - Phone:318-747-4330
Practice Address - Fax:318-746-2773
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA18544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist