MEDICARE: TITO COOMBER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	55783	TX

General Provider Information

NPI Number	:	1033718002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TITO COOMBER

Provider Business Mailing Address
First Line	:	976 KELLER PKWY
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-3608
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	976 KELLER PKWY
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-3608
Country	:	US
Telephone Number	:	817-431-5178
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2020
Last Update Date	:	10/21/2020

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Directions to “ TITO COOMBER ” Practice Location

Language	Start Address	Practice Location

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