Provider Demographics
NPI:1598194987
Name:KOONTZ, LOIS
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 WILKESBORO AVE
Mailing Address - Street 2:BLUE RIDGE PHARMACY MIDTOWN
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-4228
Mailing Address - Country:US
Mailing Address - Phone:336-838-3782
Mailing Address - Fax:336-838-2432
Practice Address - Street 1:306 WILKESBORO AVE
Practice Address - Street 2:BLUE RIDGE PHARMACY MIDTOWN
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-4228
Practice Address - Country:US
Practice Address - Phone:336-838-3782
Practice Address - Fax:336-838-2432
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC09654183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist