Healthcare Provider Details

I. General information

NPI: 1053906214
Provider Name (Legal Business Name): TRISHA COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10772 W CARSON CITY RD
GREENVILLE MI
48838-9141
US

IV. Provider business mailing address

8380 N MUSSON RD
SIX LAKES MI
48886-9520
US

V. Phone/Fax

Practice location:
  • Phone: 616-754-5203
  • Fax: 616-754-5372
Mailing address:
  • Phone: 616-821-0184
  • Fax: 616-754-5372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5303022409
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: