Provider Demographics
NPI:1023603685
Name:KOPEK, RICHARD ARTHUR
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ARTHUR
Last Name:KOPEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 OWEN RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-9193
Mailing Address - Country:US
Mailing Address - Phone:810-750-3735
Mailing Address - Fax:
Practice Address - Street 1:3700 OWEN RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-9193
Practice Address - Country:US
Practice Address - Phone:810-750-3735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022850183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist