Provider Demographics
NPI:1073539920
Name:COGBURN HEALTH CENTER PHARMACY
Entity Type:Organization
Organization Name:COGBURN HEALTH CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:251-476-4941
Mailing Address - Street 1:2651 CAMERON ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36607-3127
Mailing Address - Country:US
Mailing Address - Phone:251-476-4941
Mailing Address - Fax:
Practice Address - Street 1:2651 CAMERON ST
Practice Address - Street 2:SUITE F
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-3127
Practice Address - Country:US
Practice Address - Phone:251-476-4941
Practice Address - Fax:251-476-4780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL120095333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100100049Medicaid
0108161OtherOTHER ID NUMBER-COMMERCIAL NUMBER
AL100100049Medicaid