Provider Demographics
NPI:1679648471
Name:COBB DRUG STORE
Entity Type:Organization
Organization Name:COBB DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HARROD
Authorized Official - Middle Name:MAURICE
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:479-489-5433
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:100 FOURCHE
Mailing Address - City:OLA
Mailing Address - State:AR
Mailing Address - Zip Code:72853
Mailing Address - Country:US
Mailing Address - Phone:479-489-5433
Mailing Address - Fax:479-489-3139
Practice Address - Street 1:100 FOURCHE
Practice Address - Street 2:
Practice Address - City:OLA
Practice Address - State:AR
Practice Address - Zip Code:72853
Practice Address - Country:US
Practice Address - Phone:479-489-5433
Practice Address - Fax:479-489-3139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR05351333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0405351OtherNABP
=========OtherFED #
1220720001Medicare ID - Type Unspecified