=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285165258
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN COOPER PHARMD.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2017
-----------------------------------------------------
Last Update Date | 03/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1025 MOREHEAD MEDICAL DR STE 600
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28204-2969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-355-6095
-----------------------------------------------------
Fax | 704-355-5010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1025 MOREHEAD MEDICAL DR STE 600
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28204-2969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-355-6095
-----------------------------------------------------
Fax | 704-355-5010
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 14422
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------