Provider Demographics
NPI:1245545151
Name:COOPER, COREY DEQUAN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:DEQUAN
Last Name:COOPER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 BERGQUIST DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LACKLAND A F B
Mailing Address - State:TX
Mailing Address - Zip Code:78236-9907
Mailing Address - Country:US
Mailing Address - Phone:210-292-7216
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:SUITE 1
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9907
Practice Address - Country:US
Practice Address - Phone:210-292-7216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist