Healthcare Provider Details

I. General information

NPI: 1144539289
Provider Name (Legal Business Name): HERNDON PHARMACY AND MEDICAL SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2010
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 ELDEN ST
HERNDON VA
20170-4877
US

IV. Provider business mailing address

110 S GARFIELD ST
ARLINGTON VA
22204-1842
US

V. Phone/Fax

Practice location:
  • Phone: 202-257-9240
  • Fax:
Mailing address:
  • Phone:
  • 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

VIII. Authorized Official

Name: MR. KAMRAN AGHA- AMIRI
Title or Position: CEO
Credential:
Phone: 202-257-9240