Provider Demographics
NPI:1407304124
Name:COX, JEREMY RYAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:RYAN
Last Name:COX
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4971
Mailing Address - Country:US
Mailing Address - Phone:406-549-6163
Mailing Address - Fax:406-546-1786
Practice Address - Street 1:1003 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4971
Practice Address - Country:US
Practice Address - Phone:406-549-6163
Practice Address - Fax:406-546-1786
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-25971183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist