Healthcare Provider Details

I. General information

NPI: 1669450276
Provider Name (Legal Business Name): DEBORAH GOODRICH COUSINS CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26317 WEST WASHINGTON STREET
PETERSBURG VA
23803-0030
US

IV. Provider business mailing address

9012 CIRCLEWOOD DR
PETERSBURG VA
23803-7746
US

V. Phone/Fax

Practice location:
  • Phone: 804-524-7346
  • Fax: 804-524-4718
Mailing address:
  • Phone: 804-524-7346
  • Fax: 804-524-4718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number0230004347
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: