Provider Demographics
NPI:1316584089
Name:COOPER, DIANA SUSAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:SUSAN
Last Name:COOPER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 LOBELIA LN
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-7409
Mailing Address - Country:US
Mailing Address - Phone:517-290-7302
Mailing Address - Fax:
Practice Address - Street 1:108 W HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-1159
Practice Address - Country:US
Practice Address - Phone:517-552-0205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist