Provider Demographics
NPI:1265089031
Name:LIKES, CODY
Entity type:Individual
Prefix:DR
First Name:CODY
Middle Name:
Last Name:LIKES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 NORTHGATE MILE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-2014
Mailing Address - Country:US
Mailing Address - Phone:208-535-2553
Mailing Address - Fax:
Practice Address - Street 1:1555 NORTHGATE MILE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-2014
Practice Address - Country:US
Practice Address - Phone:208-535-2553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty