Provider Demographics
NPI:1225681190
Name:KOPPER, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:KOPPER
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 1:4501 FREDONIA AVE
Mailing Address - Street 2:
Mailing Address - City:SNYDER
Mailing Address - State:TX
Mailing Address - Zip Code:79549-5827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3500 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SNYDER
Practice Address - State:TX
Practice Address - Zip Code:79549-4635
Practice Address - Country:US
Practice Address - Phone:325-574-1683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60758183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist