Provider Demographics
NPI:1194076141
Name:MYASKOVSKY, STANISLAV
Entity type:Individual
Prefix:
First Name:STANISLAV
Middle Name:
Last Name:MYASKOVSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10580 ARROWHEAD DRIVE
Mailing Address - Street 2:FAIRFAX HEALTH CENTER
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030
Mailing Address - Country:US
Mailing Address - Phone:571-432-2680
Mailing Address - Fax:571-432-2795
Practice Address - Street 1:10580 ARROWHEAD DRIVE
Practice Address - Street 2:FAIRFAX HEALTH CENTER
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030
Practice Address - Country:US
Practice Address - Phone:571-432-2680
Practice Address - Fax:571-432-2795
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-29
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02022093471835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy