Provider Demographics
NPI:1396257689
Name:MIR, OMID (PHARMD)
Entity type:Individual
Prefix:
First Name:OMID
Middle Name:
Last Name:MIR
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5449 SERVICEBERRY ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-5010
Mailing Address - Country:US
Mailing Address - Phone:571-274-9869
Mailing Address - Fax:
Practice Address - Street 1:3611 BLADENSBURG RD
Practice Address - Street 2:
Practice Address - City:COLMAR MANOR
Practice Address - State:MD
Practice Address - Zip Code:20722-1809
Practice Address - Country:US
Practice Address - Phone:301-277-6667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25344183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist