Provider Demographics
NPI:1457364002
Name:DAVIS, JERRY WESLEY (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WESLEY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ORDWAY
Mailing Address - State:CO
Mailing Address - Zip Code:81063-1021
Mailing Address - Country:US
Mailing Address - Phone:719-267-3884
Mailing Address - Fax:719-267-4443
Practice Address - Street 1:228 MAIN ST
Practice Address - Street 2:
Practice Address - City:ORDWAY
Practice Address - State:CO
Practice Address - Zip Code:81063-1403
Practice Address - Country:US
Practice Address - Phone:719-267-3544
Practice Address - Fax:719-267-4443
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10634183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10634OtherPHARMACY LICENSE