Healthcare Provider Details

I. General information

NPI: 1194657098
Provider Name (Legal Business Name): SETH COOK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5155 E EAGLE DR
MESA AZ
85215-1211
US

IV. Provider business mailing address

5155 E EAGLE DR
MESA AZ
85215-1211
US

V. Phone/Fax

Practice location:
  • Phone: 480-690-9655
  • Fax: 480-422-8760
Mailing address:
  • Phone: 480-690-9655
  • Fax: 480-422-8760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT061474
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: