Provider Demographics
NPI:1477260586
Name:KOUSOK, CEDRICK TSINDA (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:CEDRICK
Middle Name:TSINDA
Last Name:KOUSOK
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SW WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-4712
Mailing Address - Country:US
Mailing Address - Phone:817-295-1125
Mailing Address - Fax:817-295-6610
Practice Address - Street 1:100 SW WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4712
Practice Address - Country:US
Practice Address - Phone:817-295-1125
Practice Address - Fax:817-295-6610
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17452183500000X
TX60303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX60303OtherTEXAS BOARD OF PHARMACY
AL17452OtherALABAMA BOARD OF PHARMACY