Provider Demographics
NPI:1114475118
Name:MONUMENT-FAIRFAX, LLC
Entity Type:Organization
Organization Name:MONUMENT-FAIRFAX, LLC
Other - Org Name:REVOLUTION MEDS PHARMACY, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:F
Authorized Official - Last Name:DOWNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-654-6577
Mailing Address - Street 1:11230 WAPLES MILL RD STE 115
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5026
Mailing Address - Country:US
Mailing Address - Phone:703-899-5947
Mailing Address - Fax:
Practice Address - Street 1:11230 WAPLES MILL RD STE 115
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5026
Practice Address - Country:US
Practice Address - Phone:703-899-5947
Practice Address - Fax:703-272-7497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-19
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164585OtherPK