Healthcare Provider Details

I. General information

NPI: 1679648471
Provider Name (Legal Business Name): COBB DRUG STORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FOURCHE
OLA AR
72853
US

IV. Provider business mailing address

PO BOX 219 100 FOURCHE
OLA AR
72853
US

V. Phone/Fax

Practice location:
  • Phone: 479-489-5433
  • Fax: 479-489-3139
Mailing address:
  • Phone: 479-489-5433
  • Fax: 479-489-3139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberAR05351
License Number StateAR

VIII. Authorized Official

Name: HARROD MAURICE COBB
Title or Position: PHARMACIST OWNER
Credential: PD
Phone: 479-489-5433