Basic Information
| Provider Information | |||||||||
| NPI: | 1629118757 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COOK FAMILY HEALTH CENTER PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 402 N ROGERS ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474043740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123376162 | ||||||||
| FaxNumber: | 8123301933 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 N ROGERS ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474043740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123376162 | ||||||||
| FaxNumber: | 8123301933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HURST | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8123376163 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | R.N. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 60004296A | IN | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 60004296A | 01 | IN | DEA NUMBER | OTHER |