Healthcare Provider Details

I. General information

NPI: 1760428254
Provider Name (Legal Business Name): MA DAVIS ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 W MAIN ST. SUITE A
NEWBERN TN
38059
US

IV. Provider business mailing address

625 W. MAIN ST. SUITE A
NEWBERN TN
38059
US

V. Phone/Fax

Practice location:
  • Phone: 731-627-9573
  • Fax: 731-627-3051
Mailing address:
  • Phone: 731-627-9573
  • Fax: 731-627-3051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number439
License Number StateTN

VIII. Authorized Official

Name: MR. MARK ANTHONY DAVIS
Title or Position: OWNER
Credential: PHARM D.
Phone: 731-589-0206