Basic Information
| Provider Information | |||||||||
| NPI: | 1053647669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COCKERHAM | ||||||||
| FirstName: | EMILIE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4515 CAMP BOWIE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761073836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177358185 | ||||||||
| FaxNumber: | 8177358130 | ||||||||
| Practice Location | |||||||||
| Address1: | 4515 CAMP BOWIE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761073836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177358185 | ||||||||
| FaxNumber: | 8177358130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2009 | ||||||||
| LastUpdateDate: | 11/02/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 43257 | TX | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 1780699876 | 01 | TX | PHARMACY | OTHER |