Provider Demographics
NPI:1164525127
Name:O'BRIEN, CORY MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:MICHAEL
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8627 DOE PASS
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-8840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:MI
Practice Address - Zip Code:48872
Practice Address - Country:US
Practice Address - Phone:517-625-8640
Practice Address - Fax:517-625-8642
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029125183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist