Provider Demographics
NPI:1962033308
Name:COOPER, DONALD ALLEN
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:ALLEN
Last Name:COOPER
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 1:4321 HARTLEY BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-5641
Mailing Address - Country:US
Mailing Address - Phone:478-788-1015
Mailing Address - Fax:478-788-2050
Practice Address - Street 1:4321 HARTLEY BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31216-5641
Practice Address - Country:US
Practice Address - Phone:478-788-1015
Practice Address - Fax:478-788-2050
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0241741835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist