Provider Demographics
NPI:1104110295
Name:DAVIS, MARY VONCILLE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:VONCILLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7305 SE 29TH ST
Mailing Address - Street 2:T-2061
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-6122
Mailing Address - Country:US
Mailing Address - Phone:405-455-4001
Mailing Address - Fax:405-455-4204
Practice Address - Street 1:7305 SE 29TH ST
Practice Address - Street 2:T-2061
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-6122
Practice Address - Country:US
Practice Address - Phone:405-455-4001
Practice Address - Fax:405-455-4204
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist