Provider Demographics
NPI:1669795191
Name:DAVIS, ANGELA (PHARMD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
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 1:8225 BIELBY RD
Mailing Address - Street 2:APARTMENT 12
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-1935
Mailing Address - Country:US
Mailing Address - Phone:315-269-3191
Mailing Address - Fax:
Practice Address - Street 1:1727 BLACK RIVER BLVD
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440
Practice Address - Country:US
Practice Address - Phone:315-336-8890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054302183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist