Provider Demographics
NPI:1437799079
Name:DAVIS, KELLY AUSTIN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:AUSTIN
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 1:378 MARKETPLACE PKWY
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-7266
Mailing Address - Country:US
Mailing Address - Phone:470-375-1995
Mailing Address - Fax:470-375-1996
Practice Address - Street 1:378 MARKETPLACE PKWY
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-7266
Practice Address - Country:US
Practice Address - Phone:470-375-1995
Practice Address - Fax:470-375-1996
Is Sole Proprietor?:No
Enumeration Date:2020-01-12
Last Update Date:2020-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH017050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist