Healthcare Provider Details

I. General information

NPI: 1063552263
Provider Name (Legal Business Name): OMM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14454 JEFFERSON DAVIS HWY
WOODBRIDGE VA
22191-2806
US

IV. Provider business mailing address

14454 JEFFERSON DAVIS HWY
WOODBRIDGE VA
22191-2806
US

V. Phone/Fax

Practice location:
  • Phone: 703-491-7883
  • Fax: 703-491-7923
Mailing address:
  • Phone: 703-491-7883
  • Fax: 703-491-7923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202011966
License Number StateVA

VIII. Authorized Official

Name: AMIT Y SHAH
Title or Position: OWNER
Credential: PHARMACIST-OWNER
Phone: 703-491-7883