Provider Demographics
NPI:1497042956
Name:NOVA PHARMACY LLC
Entity Type:Organization
Organization Name:NOVA PHARMACY LLC
Other - Org Name:NOVA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:TO-UYEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD,RPH
Authorized Official - Phone:703-538-5555
Mailing Address - Street 1:6023 WILSON BLVD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-1503
Mailing Address - Country:US
Mailing Address - Phone:703-538-5555
Mailing Address - Fax:703-538-5557
Practice Address - Street 1:6023 WILSON BLVD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-1503
Practice Address - Country:US
Practice Address - Phone:703-538-5555
Practice Address - Fax:703-538-5557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
VA02010044193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130996OtherPK
VA1497042956Medicaid