Provider Demographics
NPI:1730512195
Name:COOPER, KENNETH EDWARD JR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EDWARD
Last Name:COOPER
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:KENNETH
Other - Middle Name:EDWARD
Other - Last Name:COOPER
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:4371 E LOHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8255
Mailing Address - Country:US
Mailing Address - Phone:575-532-8900
Mailing Address - Fax:
Practice Address - Street 1:4371 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8255
Practice Address - Country:US
Practice Address - Phone:575-532-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP000006912183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4355051811OtherMEDICARE ID NUMBER