Provider Demographics
NPI:1811582323
Name:KOPEK, AUSTIN LOUIS-ROOS
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:LOUIS-ROOS
Last Name:KOPEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6156 FOWLERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-9362
Mailing Address - Country:US
Mailing Address - Phone:810-599-4795
Mailing Address - Fax:
Practice Address - Street 1:3850 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8593
Practice Address - Country:US
Practice Address - Phone:517-548-9511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53030316273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy