Provider Demographics
NPI:1386256238
Name:DAVIS, RYAN CLIFFORD
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:CLIFFORD
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 1:3200 N OAK STREET EXT
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-6473
Mailing Address - Country:US
Mailing Address - Phone:229-247-2553
Mailing Address - Fax:
Practice Address - Street 1:102 S 1ST ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-1171
Practice Address - Country:US
Practice Address - Phone:912-588-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist