Provider Demographics
NPI:1457309148
Name:COBBS WESTSIDE PHARMACY INC
Entity Type:Organization
Organization Name:COBBS WESTSIDE PHARMACY INC
Other - Org Name:COBBS WESTSIDE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:479-968-7180
Mailing Address - Street 1:108 SKYLINE DR
Mailing Address - Street 2:STE B
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3362
Mailing Address - Country:US
Mailing Address - Phone:479-968-7180
Mailing Address - Fax:479-967-0884
Practice Address - Street 1:108 SKYLINE DR
Practice Address - Street 2:STE B
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3362
Practice Address - Country:US
Practice Address - Phone:479-968-7180
Practice Address - Fax:479-967-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR009073336C0003X
3336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR160234407Medicaid
1992803OtherPK
0400907OtherNCPDP PROVIDER IDENTIFICATION NUMBER