Healthcare Provider Details

I. General information

NPI: 1205599495
Provider Name (Legal Business Name): NICOLE RENEE DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2021
Last Update Date: 10/15/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3875 SALEM AVE
DAYTON OH
45406-1633
US

IV. Provider business mailing address

2327 HARSHMAN RD APT 112
DAYTON OH
45424-5267
US

V. Phone/Fax

Practice location:
  • Phone: 937-277-1611
  • Fax: 937-275-8893
Mailing address:
  • Phone: 937-838-4410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number09203671
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number021022700
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: