Provider Demographics
NPI:1992802813
Name:DAVIS, LARRY THOMAS (RPH)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:THOMAS
Last Name:DAVIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:229-242-6271
Mailing Address - Fax:229-259-9029
Practice Address - Street 1:1105 MADISON HIGHWAY
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601
Practice Address - Country:US
Practice Address - Phone:229-242-0253
Practice Address - Fax:229-259-9029
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE007971183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0556050533Medicare ID - Type Unspecified