Provider Demographics
NPI:1104627504
Name:OM VIRISSAR PHARMACY, INC
Entity type:Organization
Organization Name:OM VIRISSAR PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NDE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:571-365-1833
Mailing Address - Street 1:8186 LARK BROWN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-6437
Mailing Address - Country:US
Mailing Address - Phone:443-620-9990
Mailing Address - Fax:
Practice Address - Street 1:8186 LARK BROWN RD STE 101
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6437
Practice Address - Country:US
Practice Address - Phone:443-620-9990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-21
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy