Healthcare Provider Details

I. General information

NPI: 1174151716
Provider Name (Legal Business Name): VANDORN PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5724 EDSALL RD ALEXANDRIA VA 22304
ALEXANDRIA VA
22304-4712
US

IV. Provider business mailing address

5724 EDSALL RD
ALEXANDRIA VA
22304-4712
US

V. Phone/Fax

Practice location:
  • Phone: 202-765-6110
  • Fax: 703-348-8470
Mailing address:
  • Phone: 202-765-6110
  • Fax: 703-348-8470

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 Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: YODIT GULELAT
Title or Position: OWNER/MANAGER
Credential:
Phone: 703-348-7186