Provider Demographics
NPI:1679648414
Name:KOOP, JOHN PHILLIP (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHILLIP
Last Name:KOOP
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 STATE AVE
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-7308
Mailing Address - Country:US
Mailing Address - Phone:218-828-2759
Mailing Address - Fax:218-828-2207
Practice Address - Street 1:11800 STATE AVE
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-7308
Practice Address - Country:US
Practice Address - Phone:218-828-2759
Practice Address - Fax:218-828-2207
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114002-41835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy