Provider Demographics
NPI:1063981728
Name:EPHREM, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:EPHREM
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 1:8380 GREENSBORO DR UNIT 617
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3520
Mailing Address - Country:US
Mailing Address - Phone:703-868-9216
Mailing Address - Fax:540-720-1004
Practice Address - Street 1:905 GARRISONVILLE RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-3905
Practice Address - Country:US
Practice Address - Phone:540-288-9190
Practice Address - Fax:540-720-1004
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-24
Last Update Date:2018-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204746183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist