Healthcare Provider Details

I. General information

NPI: 1164529459
Provider Name (Legal Business Name): COPPEROPOLIS PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 COSMIC CT SUITE C
COPPEROPOLIS CA
95228-9300
US

IV. Provider business mailing address

49 COSMIC CT SUITE C
COPPEROPOLIS CA
95228-9300
US

V. Phone/Fax

Practice location:
  • Phone: 209-785-8787
  • Fax:
Mailing address:
  • Phone: 209-785-8787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KEVIN TOM
Title or Position: OWNER
Credential: PHARMD
Phone: 916-394-1732