Healthcare Provider Details

I. General information

NPI: 1821698705
Provider Name (Legal Business Name): JEAN-ARNAUD MAMOUDOU JOSE KEITA PHARM.D., RPH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 RIVERTON COMMONS DR
FRONT ROYAL VA
22630-6718
US

IV. Provider business mailing address

1000 PALISADES CIR APT 1225
MANASSAS PARK VA
20111-8058
US

V. Phone/Fax

Practice location:
  • Phone: 540-635-7712
  • Fax:
Mailing address:
  • Phone: 703-870-1214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202214735
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: