Basic Information
| Provider Information | |||||||||
| NPI: | 1720679962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | CMR 402 BOX 1474 | ||||||||
| Address2: | |||||||||
| City: | APO | ||||||||
| State: | AE | ||||||||
| PostalCode: | 09180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145905222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6104 AVENUE Q SOUTH DRIVE | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064723400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2021 | ||||||||
| LastUpdateDate: | 01/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 24513 | NC | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.