Provider Demographics
NPI:1740344142
Name:COOK AND FORTENBERRY PHARMACY
Entity type:Organization
Organization Name:COOK AND FORTENBERRY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-736-3481
Mailing Address - Street 1:718 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-2938
Mailing Address - Country:US
Mailing Address - Phone:601-736-3481
Mailing Address - Fax:
Practice Address - Street 1:718 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-2938
Practice Address - Country:US
Practice Address - Phone:601-736-3481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS046-060992183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2502917OtherNABP
MS00330028Medicaid
MS1102260002Medicare ID - Type Unspecified