Provider Demographics
NPI:1063708220
Name:WAI, LEAL SIMON (RPH)
Entity type:Individual
Prefix:
First Name:LEAL
Middle Name:SIMON
Last Name:WAI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4035 PENDER RIDGE TER
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-6232
Mailing Address - Country:US
Mailing Address - Phone:832-429-5235
Mailing Address - Fax:
Practice Address - Street 1:12197 SUNSET HILLS RD
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3208
Practice Address - Country:US
Practice Address - Phone:703-478-9698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19398183500000X
VA0202209710183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist