Provider Demographics
NPI:1912508102
Name:KOPMEIER, EASTON
Entity Type:Individual
Prefix:
First Name:EASTON
Middle Name:
Last Name:KOPMEIER
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 1:5037 COUNTY ROAD B
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-2910
Mailing Address - Country:US
Mailing Address - Phone:608-553-0756
Mailing Address - Fax:
Practice Address - Street 1:3107 MARKET PL
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-6756
Practice Address - Country:US
Practice Address - Phone:608-781-8355
Practice Address - Fax:608-781-8357
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18021-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist