=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558762138
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COBRA PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2014
-----------------------------------------------------
Last Update Date | 04/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37 C LUCASVILLE-MINFORD ROAD
-----------------------------------------------------
City | LUCASVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-357-8426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37C LUCASVILLE MINFORD RD
-----------------------------------------------------
City | LUCASVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45648-9023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-259-0041
-----------------------------------------------------
Fax | 740-259-0044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/PHARMACIST IN CHARGE
-----------------------------------------------------
Name | DR. BRANDON LEE HOLBROOK
-----------------------------------------------------
Credential | PHARMD, RPH
-----------------------------------------------------
Telephone | 740-357-8426
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 02242120003
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------