Provider Demographics
NPI:1033456181
Name:COOPER, BRIAN KEITH (RPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:COOPER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3721 10TH CT
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6559
Mailing Address - Country:US
Mailing Address - Phone:772-567-2555
Mailing Address - Fax:772-567-0013
Practice Address - Street 1:1451 SEBASTIAN BLVD
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-5166
Practice Address - Country:US
Practice Address - Phone:772-581-5725
Practice Address - Fax:772-581-5863
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS40522183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist