MEDICARE: DEBORAH GOODRICH COUSINS CPHT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183700000X	Pharmacy Technician	0230004347	VA

General Provider Information

NPI Number	:	1669450276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORAH GOODRICH COUSINS CPHT

Provider Business Mailing Address
First Line	:	9012 CIRCLEWOOD DR
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-7746
Country	:	US
Telephone Number	:	804-524-7346
Fax Number	:	804-524-4718

Provider Business Practice Location Address
First Line	:	26317 WEST WASHINGTON STREET
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23803-0030
Country	:	US
Telephone Number	:	804-524-7346
Fax Number	:	804-524-4718

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	07/08/2007

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