Provider Demographics
NPI:1215481668
Name:DAVIS, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2645 KINLINWOOD CT NW
Mailing Address - Street 2:APT 5
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-8934
Mailing Address - Country:US
Mailing Address - Phone:330-703-8702
Mailing Address - Fax:
Practice Address - Street 1:5122 TUSCARAWAS ST W
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-5016
Practice Address - Country:US
Practice Address - Phone:330-478-3976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-14
Last Update Date:2016-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03233035183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist