Healthcare Provider Details

I. General information

NPI: 1508419623
Provider Name (Legal Business Name): PHILLIP ROMAN DAVIS PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

IV. Provider business mailing address

1033 GIRARD BLVD NE
ALBUQUERQUE NM
87106-2014
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-5707
  • Fax: 505-913-6452
Mailing address:
  • Phone: 262-501-1907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License NumberRP00008957
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: