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NPI Code Detail

MEDICARE: TARGET PHARMACY

MEDICARE: TARGET PHARMACY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QV0200XVA Clinic/Center0202212273VA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
10202212273OTHERVAVIRGINIA PHARMACY LICENSE

General Provider Information

NPI Number : 1205291549
Entity Type Code : Organization
Provider Name (Legal Business Name) : TARGET PHARMACY
Provider Business Mailing Address
First Line : 4310 FORTUNA CENTER PLZ
Second Line :
City : DUMFRIES
State : VA
Zip : 22025-1538
Country : US
Telephone Number : 703-586-6133
Fax Number :
Provider Business Practice Location Address
First Line : 4310 FORTUNA CENTER PLZ
Second Line :
City : DUMFRIES
State : VA
Zip : 22025-1538
Country : US
Telephone Number : 703-586-6133
Fax Number :
Authorized Official
Title or Position : PHARMACIST
Name : DR. ESSTEASE EMILE DOMINGUE
Credential : PHARMD
Telephone Number : 757-660-0013
Provider Enumeration Date : 12/30/2015
Last Update Date : 12/30/2015

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