Provider Demographics
NPI:1568910651
Name:COBLE, BRENT ENSLEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ENSLEY
Last Name:COBLE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2163 RIVER ACRES CT
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-5042
Mailing Address - Country:US
Mailing Address - Phone:360-420-6706
Mailing Address - Fax:
Practice Address - Street 1:3649 FLAKES MILL RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-5218
Practice Address - Country:US
Practice Address - Phone:770-322-2387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist