Healthcare Provider Details

I. General information

NPI: 1326712142
Provider Name (Legal Business Name): CODY MICHAEL DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 W MAIN ST
LOUISVILLE OH
44641-1335
US

IV. Provider business mailing address

646 CATHY ANN DR
BOARDMAN OH
44512-6552
US

V. Phone/Fax

Practice location:
  • Phone: 330-875-1429
  • Fax: 330-875-2753
Mailing address:
  • Phone: 330-770-7943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03440953
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: