=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316432669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELTA PHARM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2018
-----------------------------------------------------
Last Update Date | 01/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8316 ARLINGTON BLVD STE 100
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-395-4444
-----------------------------------------------------
Fax | 703-712-8869
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8316 ARLINGTON BLVD STE 100
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-5208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-395-4444
-----------------------------------------------------
Fax | 703-712-8869
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RPH/OWNER
-----------------------------------------------------
Name | EHAB SHAABAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 571-395-4444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------