Provider Demographics
NPI:1194249391
Name:DAVIS, MYRA MILLER
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:MILLER
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 1:366 FRANK MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28672-9512
Mailing Address - Country:US
Mailing Address - Phone:336-977-8358
Mailing Address - Fax:
Practice Address - Street 1:1489 MOUNT JEFFERSON RD
Practice Address - Street 2:
Practice Address - City:WEST JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28694-8336
Practice Address - Country:US
Practice Address - Phone:336-246-3119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27166183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist