Provider Demographics
NPI:1386235380
Name:DAVIS, EMILY ANN
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ANN
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 1:133 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-2636
Mailing Address - Country:US
Mailing Address - Phone:618-731-3466
Mailing Address - Fax:
Practice Address - Street 1:1401 N 8TH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1028
Practice Address - Country:US
Practice Address - Phone:618-283-0196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051039940183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist