Provider Demographics
NPI:1508467622
Name:COPELAND, MISTIE MICHELLE
Entity Type:Individual
Prefix:
First Name:MISTIE
Middle Name:MICHELLE
Last Name:COPELAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5460 EVENING LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-7715
Mailing Address - Country:US
Mailing Address - Phone:936-443-7489
Mailing Address - Fax:
Practice Address - Street 1:951 W BELT LINE RD
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-3741
Practice Address - Country:US
Practice Address - Phone:972-223-1930
Practice Address - Fax:972-223-1926
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist