Provider Demographics
NPI:1225327778
Name:COOPER, NORRIS
Entity Type:Individual
Prefix:MR
First Name:NORRIS
Middle Name:
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 1:305 6TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-4842
Mailing Address - Country:US
Mailing Address - Phone:229-985-1378
Mailing Address - Fax:229-890-3185
Practice Address - Street 1:305 6TH ST SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-4842
Practice Address - Country:US
Practice Address - Phone:229-985-1378
Practice Address - Fax:229-890-3185
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014114183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist