Provider Demographics
NPI:1972906212
Name:PRINCE WILLIAM HOSPITAL
Entity type:Organization
Organization Name:PRINCE WILLIAM HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JO
Authorized Official - Middle Name:
Authorized Official - Last Name:DAMICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-331-4180
Mailing Address - Street 1:8700 SUDLEY RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4418
Mailing Address - Country:US
Mailing Address - Phone:703-369-8171
Mailing Address - Fax:
Practice Address - Street 1:8700 SUDLEY RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4418
Practice Address - Country:US
Practice Address - Phone:703-369-8171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010009993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147638OtherPK