MEDICARE: DAVIS PHARMACY INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	003656	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2609040	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1063526036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVIS PHARMACY INC.

Provider Business Mailing Address
First Line	:	415 MOTT ST
Second Line	:
City	:	NEW MADRID
State	:	MO
Zip	:	63869-1955
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 MOTT ST
Second Line	:
City	:	NEW MADRID
State	:	MO
Zip	:	63869-1955
Country	:	US
Telephone Number	:	573-748-5205
Fax Number	:	573-748-2838

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MARY KAY DAVIS
Credential	:
Telephone Number	:	573-748-5205

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	03/29/2010

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Directions to “DAVIS PHARMACY INC. ” Practice Location

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