Healthcare Provider Details

I. General information

NPI: 1417332008
Provider Name (Legal Business Name): BRYAN COOPER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W IRONWOOD DR STE 159
COEUR D ALENE ID
83814-4401
US

IV. Provider business mailing address

700 W IRONWOOD DR STE 159
COEUR D ALENE ID
83814-4401
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-3190
  • Fax:
Mailing address:
  • Phone: 208-625-3190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH61499220
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP7329
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: