Basic Information
Provider Information
NPI: 1003143090
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DAVIS
FirstName: SERENA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7215 RIVERBROOK CT
Address2:  
City: ARLINGTON
State: TX
PostalCode: 760016793
CountryCode: US
TelephoneNumber: 8174670789
FaxNumber:  
Practice Location
Address1: 750 N WALNUT CREEK DR
Address2:  
City: MANSFIELD
State: TX
PostalCode: 760633208
CountryCode: US
TelephoneNumber: 8174775271
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/11/2009
LastUpdateDate: 11/12/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X37639TXY Pharmacy Service ProvidersPharmacist 

No ID Information.


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