Provider Demographics
NPI:1770869661
Name:DAVIS, CANDY
Entity type:Individual
Prefix:
First Name:CANDY
Middle Name:
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 1:2400 E TROPICANA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5441
Mailing Address - Country:US
Mailing Address - Phone:702-435-6289
Mailing Address - Fax:702-435-6375
Practice Address - Street 1:2400 E TROPICANA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5441
Practice Address - Country:US
Practice Address - Phone:702-435-6289
Practice Address - Fax:702-435-6375
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16185183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist