Provider Demographics
NPI:1346568409
Name:COHEN, WAYNE L (RPH)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:L
Last Name:COHEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 BURGUNDY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404-1050
Mailing Address - Country:US
Mailing Address - Phone:928-453-8795
Mailing Address - Fax:928-453-2619
Practice Address - Street 1:25 LAKE HAVASU AVE S
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6565
Practice Address - Country:US
Practice Address - Phone:928-453-2808
Practice Address - Fax:928-453-2619
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS015278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist