Provider Demographics
NPI:1699131953
Name:BROTHERS, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BROTHERS
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 1:4216 JEFFERSON OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-4082
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4216 JEFFERSON OAKS CIR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-4082
Practice Address - Country:US
Practice Address - Phone:703-898-2809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-01
Last Update Date:2016-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202213785183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist