Healthcare Provider Details

I. General information

NPI: 1861901340
Provider Name (Legal Business Name): PERSONALMED VIRGINIA PHARMACY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12007 SUNRISE VALLEY DR STE 110
RESTON VA
20191-3460
US

IV. Provider business mailing address

10370 RICHMOND AVE STE 230
HOUSTON TX
77042-4141
US

V. Phone/Fax

Practice location:
  • Phone: 844-901-7832
  • Fax: 281-305-3989
Mailing address:
  • Phone: 844-901-7832
  • Fax: 281-305-3989

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
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DELFORD DOHERTY
Title or Position: VP MANAGED CARE SERVICES
Credential: PHARM.D., PH.D., MPH
Phone: 844-901-7832