Provider Demographics
NPI:1265872675
Name:DAVIS, RYAN TIMOTHY
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:TIMOTHY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 CHRISTOPHER WAY
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6298
Mailing Address - Country:US
Mailing Address - Phone:406-239-3379
Mailing Address - Fax:
Practice Address - Street 1:115 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-4072
Practice Address - Country:US
Practice Address - Phone:406-587-9252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-29
Last Update Date:2013-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist