Provider Demographics
NPI:1285232959
Name:RYAN, ANDREW M
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:M
Last Name:RYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4250 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22206-3426
Mailing Address - Country:US
Mailing Address - Phone:703-379-2241
Mailing Address - Fax:
Practice Address - Street 1:4250 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22206-3426
Practice Address - Country:US
Practice Address - Phone:703-379-2241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202214360183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist