Provider Demographics
NPI:1356790240
Name:DAVIS, ROBERTA (DPH)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13924 NW EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:OK
Mailing Address - Zip Code:73078-9475
Mailing Address - Country:US
Mailing Address - Phone:405-373-4065
Mailing Address - Fax:
Practice Address - Street 1:13924 NW EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:OK
Practice Address - Zip Code:73078-9475
Practice Address - Country:US
Practice Address - Phone:405-373-4065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10469183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist