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General NPI Number Information
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NPI Number | 1710618129
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Entity Type | Organization
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Legal Business Name | ST THEODORE LLC
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Dates
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Enumeration Date | 06/17/2022
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Last Update Date | 03/29/2023
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Provider Practice Location Address
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Address Line | 24585 STONE CARVER DR STE 175
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City | ALDIE
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State | VA
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Zip | 20105-3255
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Country | US
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Telephone | 571-367-3914
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Fax |
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Provider Business Mailing Address
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Address Line | 24585 STONE CARVER DR STE 175
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City | ALDIE
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State | VA
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Zip | 20105-3255
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Country | US
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Telephone | 571-367-3914
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Fax |
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Authorized Official
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Title or Position | PHARMACIST IN CHARGE
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Name | EHAB TADROUS
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Credential |
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Telephone | 571-367-3914
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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