Provider Demographics
NPI:1215645064
Name:COOPER, REIDE
Entity type:Individual
Prefix:
First Name:REIDE
Middle Name:
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 1:307 PAWTUCKET BLVD UNIT 5
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-2951
Mailing Address - Country:US
Mailing Address - Phone:904-377-1166
Mailing Address - Fax:
Practice Address - Street 1:307 PAWTUCKET BLVD UNIT 5
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-2951
Practice Address - Country:US
Practice Address - Phone:904-377-1166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH240284183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC160739943270OtherDRIVER'S LICENSE