Healthcare Provider Details

I. General information

NPI: 1528337227
Provider Name (Legal Business Name): MARY KOBOLD RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2011
Last Update Date: 12/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 MAPLEWOOD CV
FLOWOOD MS
39232-8779
US

IV. Provider business mailing address

1003 MAPLEWOOD CV
FLOWOOD MS
39232-8779
US

V. Phone/Fax

Practice location:
  • Phone: 769-257-6085
  • Fax:
Mailing address:
  • Phone: 769-257-6085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberR-010681
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10990
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: