Provider Demographics
NPI:1154610038
Name:COOKEVILLE PHARMACY LLC
Entity type:Organization
Organization Name:COOKEVILLE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:HIRT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-372-2700
Mailing Address - Street 1:4505 HARDING PIKE APT 123
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-2174
Mailing Address - Country:US
Mailing Address - Phone:931-372-2700
Mailing Address - Fax:931-372-2701
Practice Address - Street 1:305 W SPRING ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3125
Practice Address - Country:US
Practice Address - Phone:931-372-2700
Practice Address - Fax:931-372-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-31
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336S0011X
TN48633336C0003X, 3336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1154610038MMedicaid
2129702OtherPK
TN1154610038MMedicaid