=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356710594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEPARTMENT OF VETERANS AFFAIRS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2015
-----------------------------------------------------
Last Update Date | 09/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 VERMONT AVE NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20420-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-461-7351
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11509 HAVENNER RD
-----------------------------------------------------
City | FAIRFAX STATION
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22039-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-461-7351
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DEPUTY CHIEF CONSULTANT
-----------------------------------------------------
Name | DR. THOMAS RYAN EMMENDORFER
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 202-461-7351
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | 5302030607
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------