Provider Demographics
NPI:1306464946
Name:BOBOTH, COREY
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:BOBOTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 4TH PARALLEL RD
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-9787
Mailing Address - Country:US
Mailing Address - Phone:509-859-2140
Mailing Address - Fax:
Practice Address - Street 1:2721 4TH PARALLEL RD
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-9787
Practice Address - Country:US
Practice Address - Phone:509-859-2140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIR60983267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist