Provider Demographics
NPI:1649817941
Name:COOMER, MYRA ROSE (RPH)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:ROSE
Last Name:COOMER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8930 W 650 S
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:IN
Mailing Address - Zip Code:46035
Mailing Address - Country:US
Mailing Address - Phone:765-418-1704
Mailing Address - Fax:
Practice Address - Street 1:2420 N LEBANON ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1183
Practice Address - Country:US
Practice Address - Phone:765-482-7021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019558A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist