Provider Demographics
NPI:1982055620
Name:DAVIS, JEREMY (PHARM D)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:DAVIS
Suffix:
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 1:164 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1912
Mailing Address - Country:US
Mailing Address - Phone:208-227-5076
Mailing Address - Fax:208-227-5079
Practice Address - Street 1:164 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1912
Practice Address - Country:US
Practice Address - Phone:208-227-5076
Practice Address - Fax:208-227-5079
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist