Provider Demographics
NPI:1073695904
Name:MCCOOK, IVEY L III
Entity Type:Individual
Prefix:
First Name:IVEY
Middle Name:L
Last Name:MCCOOK
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23630 US HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30461-6019
Mailing Address - Country:US
Mailing Address - Phone:912-764-2223
Mailing Address - Fax:912-764-2228
Practice Address - Street 1:23630A HWY 80 EAST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-764-2223
Practice Address - Fax:912-764-2228
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014054183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist