Provider Demographics
NPI:1366046849
Name:COBB, TIMOTHY DALE
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DALE
Last Name:COBB
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 1:390 NE 36TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-2508
Mailing Address - Country:US
Mailing Address - Phone:405-290-3423
Mailing Address - Fax:
Practice Address - Street 1:7001 NW 122ND ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-3924
Practice Address - Country:US
Practice Address - Phone:405-720-9303
Practice Address - Fax:405-720-6317
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist