Provider Demographics
NPI:1831715341
Name:COPAK, DANIELLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:COPAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15310 OAKDALE PL
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-7044
Mailing Address - Country:US
Mailing Address - Phone:219-696-6630
Mailing Address - Fax:
Practice Address - Street 1:1555 US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1317
Practice Address - Country:US
Practice Address - Phone:219-865-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-20
Last Update Date:2020-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020488A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty