Provider Demographics
NPI:1528691946
Name:PHARMACY ONE LLC
Entity type:Organization
Organization Name:PHARMACY ONE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:FARHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMISSIZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-910-6044
Mailing Address - Street 1:14904 JEFFERSON DAVIS HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3908
Mailing Address - Country:US
Mailing Address - Phone:703-910-6044
Mailing Address - Fax:571-572-3174
Practice Address - Street 1:14904 JEFFERSON DAVIS HWY STE 101
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3908
Practice Address - Country:US
Practice Address - Phone:703-910-6044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-13
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1528691946Medicaid