Healthcare Provider Details

I. General information

NPI: 1255658407
Provider Name (Legal Business Name): MASIH SIAVOSHAN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6224 OLD DOMINION DR
MC LEAN VA
22101-4217
US

IV. Provider business mailing address

6224 OLD DOMINION DR
MC LEAN VA
22101-4217
US

V. Phone/Fax

Practice location:
  • Phone: 703-538-6600
  • Fax: 703-241-7023
Mailing address:
  • Phone: 703-538-6600
  • Fax: 703-241-7023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202012184
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: