Provider Demographics
NPI:1205375011
Name:KOONCE, COREY LEE (PHARMD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:LEE
Last Name:KOONCE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14520 JOHN REX BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8592
Mailing Address - Country:US
Mailing Address - Phone:919-556-2434
Mailing Address - Fax:
Practice Address - Street 1:14520 JOHN REX BLVD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8592
Practice Address - Country:US
Practice Address - Phone:919-556-2434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23744183500000X
VA0202212187183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist