1457309148 NPI number — COBBS WESTSIDE PHARMACY INC

Table of content: (NPI 1457309148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457309148 NPI number — COBBS WESTSIDE PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COBBS WESTSIDE PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457309148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 SKYLINE DR
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72801-3362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-968-7180
Provider Business Mailing Address Fax Number:
479-967-0884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 SKYLINE DR
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72801-3362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-968-7180
Provider Business Practice Location Address Fax Number:
479-967-0884
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COBB
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
479-968-7180

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  AR00907 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 160234407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1992803 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com