Provider Demographics
NPI:1801837562
Name:CODY, JOHN R (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:CODY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-5260
Mailing Address - Country:US
Mailing Address - Phone:936-569-6430
Mailing Address - Fax:936-560-9358
Practice Address - Street 1:212 NORTH ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-5260
Practice Address - Country:US
Practice Address - Phone:936-569-6430
Practice Address - Fax:936-560-9358
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24428183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5509280001Medicare ID - Type Unspecified