=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033960810
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KOO YEON YOO PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2024
-----------------------------------------------------
Last Update Date | 03/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9300 DEWITT LOOP
-----------------------------------------------------
City | FORT BELVOIR
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22060-5285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-231-3224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6770 JOSEPH EDGAR CT
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22310-2667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH84245
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0202216884
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------