Provider Demographics
NPI:1942509054
Name:COONER, JACOB ROY (RPH)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ROY
Last Name:COONER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 FAIRWAY LAKES RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-8435
Mailing Address - Country:US
Mailing Address - Phone:864-229-6463
Mailing Address - Fax:
Practice Address - Street 1:311 HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2204
Practice Address - Country:US
Practice Address - Phone:864-223-7511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist