Provider Demographics
NPI:1912458654
Name:DAVIS, BRIAN CLYDE (RPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CLYDE
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 1:626 GOOSE LN
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:CT
Mailing Address - Zip Code:06238-1219
Mailing Address - Country:US
Mailing Address - Phone:860-742-5766
Mailing Address - Fax:
Practice Address - Street 1:6 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06088-9626
Practice Address - Country:US
Practice Address - Phone:866-809-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0005367183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist