Provider Demographics
NPI:1023370574
Name:COOPER, JUSTIN LEVI
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LEVI
Last Name:COOPER
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 1:7550 HILLSIDE RD APT 1820
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-8326
Mailing Address - Country:US
Mailing Address - Phone:806-274-8777
Mailing Address - Fax:
Practice Address - Street 1:5709 W AMARILLO BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-4003
Practice Address - Country:US
Practice Address - Phone:806-355-7209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27097183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist