Provider Demographics
NPI:1174129753
Name:COX, JERAD WILLIAM
Entity type:Individual
Prefix:
First Name:JERAD
Middle Name:WILLIAM
Last Name:COX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-3647
Mailing Address - Country:US
Mailing Address - Phone:406-586-3550
Mailing Address - Fax:406-586-0788
Practice Address - Street 1:1400 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-3647
Practice Address - Country:US
Practice Address - Phone:406-586-3550
Practice Address - Fax:406-586-0788
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-65963183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP8471OtherPHARMACIST