Provider Demographics
NPI:1952779530
Name:COPPOLA, KURT (RPH)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:
Last Name:COPPOLA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 BLACK RIVER BLVD N
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-3609
Mailing Address - Country:US
Mailing Address - Phone:315-339-5290
Mailing Address - Fax:
Practice Address - Street 1:300 W MANLIUS ST
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057
Practice Address - Country:US
Practice Address - Phone:315-434-9178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-12
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060289183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist