Healthcare Provider Details

I. General information

NPI: 1649065186
Provider Name (Legal Business Name): BANTAYEHU TADELE WOJU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 HOADLY RD
MANASSAS VA
20112-3436
US

IV. Provider business mailing address

5230 PORT ROYAL RD
SPRINGFIELD VA
22151-2102
US

V. Phone/Fax

Practice location:
  • Phone: 703-259-6390
  • Fax:
Mailing address:
  • Phone: 703-321-8440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202222681
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: