Provider Demographics
NPI:1558762138
Name:COBRA PHARMACY, LLC
Entity Type:Organization
Organization Name:COBRA PHARMACY, LLC
Other - Org Name:HOLBROOK'S HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HOLBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:740-357-8426
Mailing Address - Street 1:37C LUCASVILLE MINFORD RD
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-9023
Mailing Address - Country:US
Mailing Address - Phone:740-259-0041
Mailing Address - Fax:740-259-0044
Practice Address - Street 1:37 C LUCASVILLE-MINFORD ROAD
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648
Practice Address - Country:US
Practice Address - Phone:740-357-8426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-15
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02242120003333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy