Provider Demographics
NPI:1467055103
Name:DOMINGUE, ESSTEASE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ESSTEASE
Middle Name:
Last Name:DOMINGUE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 N GLEBE RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-2257
Mailing Address - Country:US
Mailing Address - Phone:571-357-6258
Mailing Address - Fax:571-297-6154
Practice Address - Street 1:740 N GLEBE RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-2257
Practice Address - Country:US
Practice Address - Phone:571-357-6258
Practice Address - Fax:571-297-6154
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202212273183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist