Provider Demographics
NPI:1366526006
Name:MARK V COBERLY
Entity type:Organization
Organization Name:MARK V COBERLY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:COBERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-896-0212
Mailing Address - Street 1:4195 MASSILLION RD
Mailing Address - Street 2:STE B
Mailing Address - City:UNION TOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685
Mailing Address - Country:US
Mailing Address - Phone:330-896-0212
Mailing Address - Fax:330-896-0682
Practice Address - Street 1:4195 MASSILLION RD
Practice Address - Street 2:STE B
Practice Address - City:UNION TOWN
Practice Address - State:OH
Practice Address - Zip Code:44685
Practice Address - Country:US
Practice Address - Phone:330-896-0212
Practice Address - Fax:330-896-0682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
OH03 2 12837183500000X
OH02588950333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0573955Medicaid
3642750OtherOTHER ID NUMBER-COMMERCIAL NUMBER