Healthcare Provider Details

I. General information

NPI: 1073539920
Provider Name (Legal Business Name): COGBURN HEALTH CENTER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 CAMERON ST SUITE F
MOBILE AL
36607-3127
US

IV. Provider business mailing address

2651 CAMERON ST SUITE F
MOBILE AL
36607-3127
US

V. Phone/Fax

Practice location:
  • Phone: 251-476-4941
  • Fax: 251-476-4780
Mailing address:
  • Phone: 251-476-4941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number120095
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RONNIE CANNON
Title or Position: DIRECTOR OF PHARMACY
Credential: RPH
Phone: 251-476-4941