Provider Demographics
NPI:1487054623
Name:DAVILA, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DAVILA
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 1:303 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-2222
Mailing Address - Country:US
Mailing Address - Phone:219-924-9540
Mailing Address - Fax:219-922-9535
Practice Address - Street 1:303 N BROAD ST
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-2222
Practice Address - Country:US
Practice Address - Phone:219-924-9540
Practice Address - Fax:219-922-9535
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054017700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist