Provider Demographics
NPI:1326648825
Name:COOPER, CODY M (CPHT)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:M
Last Name:COOPER
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7117 19TH ST APT 1603
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-1376
Mailing Address - Country:US
Mailing Address - Phone:806-778-7935
Mailing Address - Fax:
Practice Address - Street 1:12815 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-5677
Practice Address - Country:US
Practice Address - Phone:806-776-8915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX217641183700000X
NMPT00011253183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician