Provider Demographics
NPI:1346645876
Name:COOPER, DAVID ALPHONSO
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALPHONSO
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:ALPHONSO
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:2250 NW 26TH ST
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-5503
Mailing Address - Country:US
Mailing Address - Phone:507-977-2020
Mailing Address - Fax:507-977-2010
Practice Address - Street 1:2250 NW 26TH ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-5503
Practice Address - Country:US
Practice Address - Phone:507-977-2020
Practice Address - Fax:507-977-2010
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116865183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist