Provider Demographics
NPI:1811505118
Name:DAVIS, DENNIS WILSON III (PHARM D)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:WILSON
Last Name:DAVIS
Suffix:III
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4878 170TH LN NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-1717
Mailing Address - Country:US
Mailing Address - Phone:763-807-3606
Mailing Address - Fax:
Practice Address - Street 1:2018 15TH ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-0716
Practice Address - Country:US
Practice Address - Phone:507-281-1676
Practice Address - Fax:507-281-2953
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124957183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN124957OtherPHARMACIST LICESNE