Provider Demographics
NPI:1033960992
Name:COPACIA, CLINT
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:COPACIA
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 1:4504 W SPRUCE ST APT 326
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5885
Mailing Address - Country:US
Mailing Address - Phone:586-823-1035
Mailing Address - Fax:
Practice Address - Street 1:1839 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8900
Practice Address - Country:US
Practice Address - Phone:727-894-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS66387183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty