MEDICARE: COPHARMA INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy	12480	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2141122	OTHER		PK

General Provider Information

NPI Number	:	1215378922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COPHARMA INC

Provider Business Mailing Address
First Line	:	127 PRATT DR
Second Line	:
City	:	CORINTH
State	:	MS
Zip	:	38834-6026
Country	:	US
Telephone Number	:	662-594-1594
Fax Number	:	662-594-1864

Provider Business Practice Location Address
First Line	:	127 PRATT DR
Second Line	:
City	:	CORINTH
State	:	MS
Zip	:	38834-6026
Country	:	US
Telephone Number	:	662-594-1594
Fax Number	:	662-594-1864

Authorized Official
Title or Position	:	OWNER
Name	:	DONALD KING
Credential	:
Telephone Number	:	662-594-1594

Provider Enumeration Date	:	07/10/2013
Last Update Date	:	07/25/2013

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Directions to “COPHARMA INC ” Practice Location

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