Healthcare Provider Details

I. General information

NPI: 1588963284
Provider Name (Legal Business Name): LAURA R KOOP PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5185 S 9TH ST
MILWAUKEE WI
53221-3627
US

IV. Provider business mailing address

5185 S 9TH ST
MILWAUKEE WI
53221-3627
US

V. Phone/Fax

Practice location:
  • Phone: 800-762-1407
  • Fax:
Mailing address:
  • Phone: 800-762-1407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number16186-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: