Healthcare Provider Details

I. General information

NPI: 1366526006
Provider Name (Legal Business Name): MARK V COBERLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4195 MASSILLION RD STE B
UNION TOWN OH
44685
US

IV. Provider business mailing address

4195 MASSILLION RD STE B
UNION TOWN OH
44685
US

V. Phone/Fax

Practice location:
  • Phone: 330-896-0212
  • Fax: 330-896-0682
Mailing address:
  • Phone: 330-896-0212
  • Fax: 330-896-0682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03 2 12837
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number02588950
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARK COBERLY
Title or Position: OWNER
Credential:
Phone: 330-896-0212