Provider Demographics
NPI:1083901763
Name:PLAISTED, CODY RAY (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:CODY
Middle Name:RAY
Last Name:PLAISTED
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 E ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-4032
Mailing Address - Country:US
Mailing Address - Phone:307-399-5957
Mailing Address - Fax:
Practice Address - Street 1:3480 E ROUTE 66
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-4032
Practice Address - Country:US
Practice Address - Phone:307-399-5957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3450183500000X
AZS019113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist