Provider Demographics
NPI:1386095156
Name:COBB, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:COBB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2881
Mailing Address - Country:US
Mailing Address - Phone:601-545-2056
Mailing Address - Fax:604-545-3945
Practice Address - Street 1:100 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2881
Practice Address - Country:US
Practice Address - Phone:601-545-2056
Practice Address - Fax:604-545-3945
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-07758183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist