Healthcare Provider Details

I. General information

NPI: 1053216010
Provider Name (Legal Business Name): MAHMOUD NASSRALLAH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4861 S AMHERST HWY
MADISON HEIGHTS VA
24572-2497
US

IV. Provider business mailing address

119 CORNERSTONE ST APT 203
LYNCHBURG VA
24502-5385
US

V. Phone/Fax

Practice location:
  • Phone: 434-221-2032
  • Fax:
Mailing address:
  • Phone: 434-221-2032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202223971
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: