1730425091 NPI number — DR. TARA RENAE COCKERHAM PHARMD

Table of content: DR. TARA RENAE COCKERHAM PHARMD (NPI 1730425091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730425091 NPI number — DR. TARA RENAE COCKERHAM PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COCKERHAM
Provider First Name:
TARA
Provider Middle Name:
RENAE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1730425091
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1121 ALDERMAN DR
Provider Second Line Business Mailing Address:
SUITE 112
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30005-5463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-672-4209
Provider Business Mailing Address Fax Number:
678-672-4199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1121 ALDERMAN DR
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
ALPHARETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30005-5463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-672-4209
Provider Business Practice Location Address Fax Number:
678-672-4199
Provider Enumeration Date:
12/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH020402 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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