Healthcare Provider Details

I. General information

NPI: 1255738076
Provider Name (Legal Business Name): PROSPERITY RX FAIRFAX INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2014
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 PROSPERITY AVE STE 200
FAIRFAX VA
22031-4354
US

IV. Provider business mailing address

2740 PROSPERITY AVE SUITE 200
FAIRFAX VA
22031-4353
US

V. Phone/Fax

Practice location:
  • Phone: 703-334-5180
  • Fax: 703-620-2030
Mailing address:
  • Phone: 703-334-5180
  • Fax: 703-620-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201004617
License Number StateVA

VIII. Authorized Official

Name: FRANK ODEH
Title or Position: PRESIDENT
Credential:
Phone: 703-517-4779