Provider Demographics
NPI:1528463668
Name:COBURN, MARK (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:COBURN
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 1:604 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1520
Mailing Address - Country:US
Mailing Address - Phone:208-263-1408
Mailing Address - Fax:208-265-8784
Practice Address - Street 1:604 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1520
Practice Address - Country:US
Practice Address - Phone:208-263-1408
Practice Address - Fax:208-265-8784
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP3991183500000X
WAPH000098891835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric