Provider Demographics
NPI:1063923712
Name:WELLER, COURTNEY (PHARMD)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:WELLER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:519 W EL PASO ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-4044
Mailing Address - Country:US
Mailing Address - Phone:918-340-4656
Mailing Address - Fax:
Practice Address - Street 1:18741 E RED FOX TRL
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-8341
Practice Address - Country:US
Practice Address - Phone:612-777-4536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-21
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK16121OtherBOARD OF PHARMACY