Provider Demographics
NPI:1992445415
Name:YANTSIDES, THEODORE JR (PHARM D)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:YANTSIDES
Suffix:JR
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11620 MONUMENT DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-8706
Mailing Address - Country:US
Mailing Address - Phone:703-653-1651
Mailing Address - Fax:
Practice Address - Street 1:11620 MONUMENT DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-8706
Practice Address - Country:US
Practice Address - Phone:703-653-1651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA020220817183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist