Provider Demographics
NPI:1194004119
Name:COWAN, KIM BULLOCK (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:BULLOCK
Last Name:COWAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988 BURLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-5705
Mailing Address - Country:US
Mailing Address - Phone:336-504-0402
Mailing Address - Fax:336-599-3624
Practice Address - Street 1:988 BURLINGTON RD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-5705
Practice Address - Country:US
Practice Address - Phone:336-504-0402
Practice Address - Fax:336-599-3624
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8386183500000X
VA0214000933183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist