Provider Demographics
NPI:1316005556
Name:COOPER, MICHELE DIANE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:DIANE
Last Name:COOPER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W BROADWAY ST
Mailing Address - Street 2:BOX 331
Mailing Address - City:EAGLE GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:50533-1711
Mailing Address - Country:US
Mailing Address - Phone:515-448-3814
Mailing Address - Fax:515-448-5429
Practice Address - Street 1:311 W BROADWAY ST
Practice Address - Street 2:BOX 331
Practice Address - City:EAGLE GROVE
Practice Address - State:IA
Practice Address - Zip Code:50533-1711
Practice Address - Country:US
Practice Address - Phone:515-448-3814
Practice Address - Fax:515-448-5429
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist