Basic Information
| Provider Information | |||||||||
| NPI: | 1225365265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | BERNARD | ||||||||
| NamePrefix: | |||||||||
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| Credential: | R.PH. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7215 RIVERBROOK CT | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760016793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174670789 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6551 FOREST HILL DR | ||||||||
| Address2: | |||||||||
| City: | FOREST HILL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761401205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174782952 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2009 | ||||||||
| LastUpdateDate: | 11/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 32614 | TX | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.