Healthcare Provider Details

I. General information

NPI: 1740885086
Provider Name (Legal Business Name): POWUM BENNAM PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16793 CAPON TREE LN
WOODBRIDGE VA
22191-5134
US

IV. Provider business mailing address

9555 KINGS CHARTER DR STE D
ASHLAND VA
23005-7994
US

V. Phone/Fax

Practice location:
  • Phone: 571-481-1842
  • Fax:
Mailing address:
  • Phone: 800-753-0596
  • Fax: 804-799-7917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202216219
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: