Healthcare Provider Details

I. General information

NPI: 1801035548
Provider Name (Legal Business Name): PROSPERITY PRINCE WILLIAM RX INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8644 SUDLEY RD SUITE 120
MANASSAS VA
20110-4417
US

IV. Provider business mailing address

8644 SUDLEY RD SUITE 120
MANASSAS VA
20110-4417
US

V. Phone/Fax

Practice location:
  • Phone: 703-334-5180
  • Fax: 703-334-5184
Mailing address:
  • Phone: 703-334-5180
  • Fax: 703-334-5184

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 Number0201004275
License Number StateVA

VIII. Authorized Official

Name: FRANK ODEH
Title or Position: PRESIDENT
Credential: RPH
Phone: 571-730-1130