MEDICARE: JORDAN BRADLEY DAVIS

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	183500000X	Pharmacist	024773	GA

General Provider Information

NPI Number	:	1851607105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN BRADLEY DAVIS

Provider Business Mailing Address
First Line	:	409 TATTNALL ST
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31401-4213
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1955 E MONTGOMERY XRD
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31406-5036
Country	:	US
Telephone Number	:	912-351-0743
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2010
Last Update Date	:	08/25/2010

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