Provider Demographics
NPI:1427639095
Name:MONDVILLE-DAVIS, JASON (CPHT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MONDVILLE-DAVIS
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 E MANHATTAN BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-1471
Mailing Address - Country:US
Mailing Address - Phone:419-729-2907
Mailing Address - Fax:
Practice Address - Street 1:810 E MANHATTAN BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-1471
Practice Address - Country:US
Practice Address - Phone:419-729-2907
Practice Address - Fax:419-729-2834
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09315184183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH09315184OtherOHIO BOARD OF PHARMACY
30128541OtherPTCB