Provider Demographics
NPI:1154816080
Name:COPELAND, KELLY (RPH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COPELAND
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10825 WEATHER VANE RD
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23238-4157
Mailing Address - Country:US
Mailing Address - Phone:804-306-2373
Mailing Address - Fax:
Practice Address - Street 1:10825 WEATHER VANE RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23238-4157
Practice Address - Country:US
Practice Address - Phone:804-306-2373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-23
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHR2205183500000X
FLPS44310183500000X
GARPH021434183500000X
AL14485183500000X
VA0202012937183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist