Provider Demographics
NPI:1124170816
Name:COOK, KEVIN WADE (PHARMACIST)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WADE
Last Name:COOK
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2301 WESTWOOD CV
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-5284
Mailing Address - Country:US
Mailing Address - Phone:731-285-0844
Mailing Address - Fax:731-285-0885
Practice Address - Street 1:2490 PARR AVE STE 9
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2030
Practice Address - Country:US
Practice Address - Phone:731-285-0844
Practice Address - Fax:731-285-0885
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21780183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist