Healthcare Provider Details

I. General information

NPI: 1639220684
Provider Name (Legal Business Name): JERRY CARL DAVIS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W 2ND ST
KENLY NC
27542
US

IV. Provider business mailing address

1230 PINEY GROVE CHURCH RD
KENLY NC
27542
US

V. Phone/Fax

Practice location:
  • Phone: 919-284-2010
  • Fax: 919-284-2231
Mailing address:
  • Phone: 919-284-3570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number05124
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: