Provider Demographics
NPI:1619146883
Name:COCHRAN OPTICAL DISPENSARY
Entity Type:Organization
Organization Name:COCHRAN OPTICAL DISPENSARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:COCHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-289-9581
Mailing Address - Street 1:PO BOX 960
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-0960
Mailing Address - Country:US
Mailing Address - Phone:662-289-9581
Mailing Address - Fax:662-289-9967
Practice Address - Street 1:118 W NORTH ST
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3211
Practice Address - Country:US
Practice Address - Phone:662-289-9581
Practice Address - Fax:662-289-9967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS056063332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00089021Medicaid
MS0464740001Medicare NSC