Healthcare Provider Details

I. General information

NPI: 1699929075
Provider Name (Legal Business Name): WOODBRIDGE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14904 JEFFERSON DAVIS HWY SUITE 206
WOODBRIDGE VA
22191-3908
US

IV. Provider business mailing address

14904 JEFFERSON DAVIS HWY SUITE 206
WOODBRIDGE VA
22191-3908
US

V. Phone/Fax

Practice location:
  • Phone: 703-491-6802
  • Fax: 703-491-6804
Mailing address:
  • Phone: 703-491-6802
  • Fax: 703-491-6804

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

VIII. Authorized Official

Name: MR. THOMAS MOORE
Title or Position: PIC
Credential:
Phone: 703-491-6802