Provider Demographics
NPI:1013356427
Name:LANDMARK PROFESSIONAL PHARMACY,LLC
Entity Type:Organization
Organization Name:LANDMARK PROFESSIONAL PHARMACY,LLC
Other - Org Name:LANDMARK PROFESSIONAL PHARMACY,LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBAYE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:703-585-3059
Mailing Address - Street 1:5249 DUKE ST UNIT LL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-2926
Mailing Address - Country:US
Mailing Address - Phone:703-212-0200
Mailing Address - Fax:703-212-0202
Practice Address - Street 1:5249 DUKE ST UNIT LL
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-2926
Practice Address - Country:US
Practice Address - Phone:703-212-0200
Practice Address - Fax:703-212-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010045273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140651OtherPK
VA6946950001Medicare NSC
2140651OtherPK