Provider Demographics
NPI:1730588641
Name:PHILLIPS, CODY (PHARMD)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 ROAD 138
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-9658
Mailing Address - Country:US
Mailing Address - Phone:307-421-0512
Mailing Address - Fax:
Practice Address - Street 1:489 ROAD 138
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-9658
Practice Address - Country:US
Practice Address - Phone:307-421-0512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3154183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY3154OtherPHARMACY