Provider Demographics
NPI:1689278491
Name:COOKE, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:COOKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 WEKIVA SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-3364
Mailing Address - Country:US
Mailing Address - Phone:407-862-8086
Mailing Address - Fax:407-862-5458
Practice Address - Street 1:3905 WEKIVA SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-3364
Practice Address - Country:US
Practice Address - Phone:407-862-8086
Practice Address - Fax:407-862-5458
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23124183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist