Provider Demographics
NPI:1508402116
Name:COOK, KEVIN JOE (RPH)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOE
Last Name:COOK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 S COLLEGE MALL RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6290
Mailing Address - Country:US
Mailing Address - Phone:812-345-1020
Mailing Address - Fax:
Practice Address - Street 1:1175 S COLLEGE MALL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6290
Practice Address - Country:US
Practice Address - Phone:812-333-2819
Practice Address - Fax:812-323-4304
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017573A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist