=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861535098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIMI NGOC TRAN-LY PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2007
-----------------------------------------------------
Last Update Date | 05/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5999 BURKE COMMONS RD
-----------------------------------------------------
City | BURKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22015-2880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-249-7919
-----------------------------------------------------
Fax | 703-249-7787
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12691 HERON RIDGE DR
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-6637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-213-7179
-----------------------------------------------------
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 | 0202205760
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 17584
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PH100000497
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------