Healthcare Provider Details

I. General information

NPI: 1265182117
Provider Name (Legal Business Name): MUSTAFA QUTACHI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 AMHERST ST
WINCHESTER VA
22601-3801
US

IV. Provider business mailing address

20381 FALLSWAY TER
STERLING VA
20165-5162
US

V. Phone/Fax

Practice location:
  • Phone: 540-662-2573
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202216390
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: