Provider Demographics
NPI:1407936370
Name:KOERPERICK, MARY ELLEN (RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:KOERPERICK
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 1:11349 HIGHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52003-9649
Mailing Address - Country:US
Mailing Address - Phone:563-583-4282
Mailing Address - Fax:
Practice Address - Street 1:2255 JOHN F KENNEDY RD
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2846
Practice Address - Country:US
Practice Address - Phone:563-588-8703
Practice Address - Fax:563-588-8732
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAK-15058183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist