Basic Information
| Provider Information | |||||||||
| NPI: | 1871845644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH, DPH, MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVIS | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1128 TARRYTOWN LN | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291703545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037941581 | ||||||||
| FaxNumber: | 8037943737 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 JIMMY MARTIN CIR | ||||||||
| Address2: | |||||||||
| City: | GASTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290539242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037945233 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2012 | ||||||||
| LastUpdateDate: | 10/03/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 5385 | SC | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.