Provider Demographics
NPI:1407259153
Name:COCHRAN, TOM
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:COCHRAN
Suffix:
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 1:2843 E SUNSHINE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2048
Mailing Address - Country:US
Mailing Address - Phone:417-227-1000
Mailing Address - Fax:417-227-1104
Practice Address - Street 1:2843 E SUNSHINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2048
Practice Address - Country:US
Practice Address - Phone:417-227-1000
Practice Address - Fax:417-227-1104
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029227183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600120141Medicaid