Provider Demographics
NPI:1174854699
Name:COOPER, DERRICK CHRISTOPHER (RPH)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:CHRISTOPHER
Last Name:COOPER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FLAGLER PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-5967
Mailing Address - Country:US
Mailing Address - Phone:386-517-0010
Mailing Address - Fax:386-439-6850
Practice Address - Street 1:111 FLAGLER PLAZA DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-5967
Practice Address - Country:US
Practice Address - Phone:386-517-0010
Practice Address - Fax:386-439-6850
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 43069183500000X
NY043376183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist