Provider Demographics
NPI:1285740910
Name:COOPER, MARK CHARLES (RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:CHARLES
Last Name:COOPER
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:PO BOX 537
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-0537
Mailing Address - Country:US
Mailing Address - Phone:478-272-1822
Mailing Address - Fax:478-294-9562
Practice Address - Street 1:132 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-6116
Practice Address - Country:US
Practice Address - Phone:478-272-1822
Practice Address - Fax:478-294-9562
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9495183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist