MEDICARE: MR. ROSS THOMAS COOK R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302020209	MI

General Provider Information

NPI Number	:	1407939903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROSS THOMAS COOK R.PH.

Provider Business Mailing Address
First Line	:	759 GRAY RD SE
Second Line	:
City	:	FIFE LAKE
State	:	MI
Zip	:	49633-8248
Country	:	US
Telephone Number	:	231-369-2516
Fax Number	:	231-314-5900

Provider Business Practice Location Address
First Line	:	2772 GARFIELD RD N
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-5004
Country	:	US
Telephone Number	:	231-922-9933
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/08/2007

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