=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386534089
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY ALLEN DAVIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2025
-----------------------------------------------------
Last Update Date | 07/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 SOUTHWEST DR
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-5827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-268-1743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7021 E JOHNSON AVE
-----------------------------------------------------
City | BROOKLAND
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72417-8990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-926-0569
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PD07346
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------