Provider Demographics
NPI:1902533672
Name:COTHREN, JIMMY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:
Last Name:COTHREN
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 1:3475 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6781
Mailing Address - Country:US
Mailing Address - Phone:208-380-0306
Mailing Address - Fax:
Practice Address - Street 1:3475 E 17TH ST
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6781
Practice Address - Country:US
Practice Address - Phone:208-380-0306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP10098183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist