Provider Demographics
NPI:1437573821
Name:COVENTRY, DOUGLAS
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:COVENTRY
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 1:1236 MOZART DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-6625
Mailing Address - Country:US
Mailing Address - Phone:757-636-2143
Mailing Address - Fax:757-868-7922
Practice Address - Street 1:498 WYTHE CREEK RD
Practice Address - Street 2:
Practice Address - City:POQUOSON
Practice Address - State:VA
Practice Address - Zip Code:23662-1936
Practice Address - Country:US
Practice Address - Phone:757-868-9261
Practice Address - Fax:757-868-7922
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009376183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist