Healthcare Provider Details

I. General information

NPI: 1255432795
Provider Name (Legal Business Name): OMM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 03/07/2023
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 Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201003734
License Number StateVA

VIII. Authorized Official

Name: MR. AMIT Y SHAH
Title or Position: OWNER
Credential: RPH
Phone: 703-491-7883