Provider Demographics
NPI:1245968478
Name:DAVIS, DUSTIN
Entity type:Individual
Prefix:
First Name:DUSTIN
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:PO BOX 376
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-0376
Mailing Address - Country:US
Mailing Address - Phone:989-539-4380
Mailing Address - Fax:989-539-2878
Practice Address - Street 1:161 BEECH STREET
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625
Practice Address - Country:US
Practice Address - Phone:989-539-4380
Practice Address - Fax:989-539-2878
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303006672183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician