Provider Demographics
NPI:1962098301
Name:DAVIS, COREY LYNN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3042 CROATIA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-4175
Mailing Address - Country:US
Mailing Address - Phone:618-830-9681
Mailing Address - Fax:
Practice Address - Street 1:4401 W PINE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2301
Practice Address - Country:US
Practice Address - Phone:314-533-1081
Practice Address - Fax:314-533-1082
Is Sole Proprietor?:No
Enumeration Date:2020-12-20
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012025402183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist