Provider Demographics
NPI:1033486642
Name:COPUS, LARRY DANA (RPH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DANA
Last Name:COPUS
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 1:79945 BOQUERON WAY
Mailing Address - Street 2:
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-1411
Mailing Address - Country:US
Mailing Address - Phone:760-360-5131
Mailing Address - Fax:
Practice Address - Street 1:42010 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-9610
Practice Address - Country:US
Practice Address - Phone:760-772-9122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39333183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1740295013OtherNPI