Provider Demographics
NPI:1124871959
Name:KING STREET APOTHECARY
Entity type:Organization
Organization Name:KING STREET APOTHECARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:BENYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MITIKU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-879-3477
Mailing Address - Street 1:4680 KING ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1215
Mailing Address - Country:US
Mailing Address - Phone:703-879-3477
Mailing Address - Fax:
Practice Address - Street 1:4680 KING ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1215
Practice Address - Country:US
Practice Address - Phone:703-879-3477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy