Provider Demographics
NPI:1801168695
Name:DAVIS, EDWARD C III (RPH)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:C
Last Name:DAVIS
Suffix:III
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 1:4354 186TH ST
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-4593
Mailing Address - Country:US
Mailing Address - Phone:708-798-3456
Mailing Address - Fax:
Practice Address - Street 1:940 S FRONTAGE RD STE 1900
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-5033
Practice Address - Country:US
Practice Address - Phone:630-985-7189
Practice Address - Fax:630-985-7438
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051031565183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist