Healthcare Provider Details

I. General information

NPI: 1740630862
Provider Name (Legal Business Name): BELLEVUE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 S CAPITOL ST SW
WASHINGTON DC
20032-2308
US

IV. Provider business mailing address

3939 S CAPITOL ST SW SUITE C1
WASHINGTON DC
20032-2308
US

V. Phone/Fax

Practice location:
  • Phone: 202-629-4221
  • Fax: 202-629-4592
Mailing address:
  • Phone: 301-404-6067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. KAPIAMBA MUTEBA
Title or Position: OWNER
Credential:
Phone: 301-404-6067