Provider Demographics
NPI:1720679962
Name:COOPER, RANDY WILLIAM
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:WILLIAM
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:CMR 402 BOX 1474
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180
Mailing Address - Country:US
Mailing Address - Phone:314-590-5222
Mailing Address - Fax:
Practice Address - Street 1:6104 AVENUE Q SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79412
Practice Address - Country:US
Practice Address - Phone:806-472-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-31
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist