Provider Demographics
NPI:1538496708
Name:COFFMAN, GARY CODY
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:CODY
Last Name:COFFMAN
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 1:508 SLOAN ST
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5471
Mailing Address - Country:US
Mailing Address - Phone:817-599-9155
Mailing Address - Fax:
Practice Address - Street 1:1317 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5528
Practice Address - Country:US
Practice Address - Phone:817-594-5771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX42261183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist