Provider Demographics
NPI:1467975565
Name:TDS HEALTH
Entity Type:Organization
Organization Name:TDS HEALTH
Other - Org Name:TDS HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:N
Authorized Official - Last Name:KINTU
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:703-878-1837
Mailing Address - Street 1:4215 DALE BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-2243
Mailing Address - Country:US
Mailing Address - Phone:034-571-0497
Mailing Address - Fax:571-659-9028
Practice Address - Street 1:4215 DALE BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-2243
Practice Address - Country:US
Practice Address - Phone:703-457-1049
Practice Address - Fax:571-659-9028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-20
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336L0003X, 3336L0003X, 3336M0002X
VA0201004792333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1467975565Medicaid