Provider Demographics
NPI:1962006676
Name:COOPER, COURTNEY ELIZABETH
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ELIZABETH
Last Name:COOPER
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 1:246 WATERFORD LN
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602-6225
Mailing Address - Country:US
Mailing Address - Phone:540-877-4504
Mailing Address - Fax:
Practice Address - Street 1:11160 S LAKES DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-4327
Practice Address - Country:US
Practice Address - Phone:703-620-6585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202218980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist