Provider Demographics
NPI:1053906214
Name:COOPER, TRISHA
Entity type:Individual
Prefix:
First Name:TRISHA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8380 N MUSSON RD
Mailing Address - Street 2:
Mailing Address - City:SIX LAKES
Mailing Address - State:MI
Mailing Address - Zip Code:48886-9520
Mailing Address - Country:US
Mailing Address - Phone:616-821-0184
Mailing Address - Fax:616-754-5372
Practice Address - Street 1:10772 W CARSON CITY RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-9141
Practice Address - Country:US
Practice Address - Phone:616-754-5203
Practice Address - Fax:616-754-5372
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303022409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist