Provider Demographics
NPI:1063423853
Name:DAVIS, JILL LANE (RPH)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:LANE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4149 CRAVEN PINES RD
Mailing Address - Street 2:
Mailing Address - City:SOPHIA
Mailing Address - State:NC
Mailing Address - Zip Code:27350-8059
Mailing Address - Country:US
Mailing Address - Phone:336-861-3217
Mailing Address - Fax:
Practice Address - Street 1:11220 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-2891
Practice Address - Country:US
Practice Address - Phone:336-434-2776
Practice Address - Fax:336-434-5441
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00006139183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist