Provider Demographics
NPI:1467052845
Name:FIRESTONE, TINA (RPH)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FIRESTONE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39991 BRADDOCK RD
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-2782
Mailing Address - Country:US
Mailing Address - Phone:703-307-8316
Mailing Address - Fax:
Practice Address - Street 1:6530 TRADING SQ
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-2278
Practice Address - Country:US
Practice Address - Phone:703-468-2465
Practice Address - Fax:703-468-2446
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204866183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist