Provider Demographics
NPI:1992094304
Name:COOK, BENJAMIN JESSE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JESSE
Last Name:COOK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 W CHINDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83714-1468
Mailing Address - Country:US
Mailing Address - Phone:208-323-7036
Mailing Address - Fax:208-323-7036
Practice Address - Street 1:5425 W CHINDEN BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:ID
Practice Address - Zip Code:83714-1468
Practice Address - Country:US
Practice Address - Phone:208-323-7036
Practice Address - Fax:208-323-7036
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6104183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCS12296OtherIDAHO CONTROLLED SUBSTANCE REGISTRATION
IDP6104OtherIDAHO PHARMACIST LICENSE