Provider Demographics
NPI:1205599495
Name:DAVIS, NICOLE RENEE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2327 HARSHMAN RD APT 112
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-5267
Mailing Address - Country:US
Mailing Address - Phone:937-838-4410
Mailing Address - Fax:
Practice Address - Street 1:3875 SALEM AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1633
Practice Address - Country:US
Practice Address - Phone:937-277-1611
Practice Address - Fax:937-275-8893
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0210227003336C0003X
OH09203671183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy