Provider Demographics
NPI:1386312387
Name:GHADERI, REZA
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:GHADERI
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 1:907 LINCOLN AVE # 907
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-2512
Mailing Address - Country:US
Mailing Address - Phone:703-307-2139
Mailing Address - Fax:
Practice Address - Street 1:907 LINCOLN AVE # 907
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-2512
Practice Address - Country:US
Practice Address - Phone:703-307-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011892183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202011892OtherVA LICENSE
VA4545Medicaid
VA0202011892Medicaid
VA4545Other0202011892