Basic Information
Provider Information
NPI: 1003291410
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: COOK
FirstName: TAMARA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 10139 157TH ST N
Address2:  
City: JUPITER
State: FL
PostalCode: 334789372
CountryCode: US
TelephoneNumber: 5615961238
FaxNumber:  
Practice Location
Address1: 3200 OLD BOYNTON RD
Address2:  
City: BOYNTON BEACH
State: FL
PostalCode: 334366506
CountryCode: US
TelephoneNumber: 5617424055
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/27/2015
LastUpdateDate: 11/04/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 11/04/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000XPS59528FLN Pharmacy Service ProvidersPharmacist 
183500000X36207SCY Pharmacy Service ProvidersPharmacist 

No ID Information.


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