Provider Demographics
NPI:1386344786
Name:DAVIS, TOMMY W (PHARMACIST)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 758
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-0758
Mailing Address - Country:US
Mailing Address - Phone:417-451-9450
Mailing Address - Fax:417-451-8903
Practice Address - Street 1:530 S MAIDEN LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-3084
Practice Address - Country:US
Practice Address - Phone:417-782-7209
Practice Address - Fax:417-782-7727
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO040945183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist