Provider Demographics
NPI:1063134823
Name:COOLE, KENDRA JILLIAN
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:JILLIAN
Last Name:COOLE
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 1:3150 W SHAW AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3215
Mailing Address - Country:US
Mailing Address - Phone:559-276-8926
Mailing Address - Fax:
Practice Address - Street 1:3150 W SHAW AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3215
Practice Address - Country:US
Practice Address - Phone:559-276-8926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84985183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA84985Other84985