Provider Demographics
NPI:1508575929
Name:PROCTOR, SALLY (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:
Last Name:PROCTOR
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 1:8617 OAK CHASE CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX STA
Mailing Address - State:VA
Mailing Address - Zip Code:22039-3331
Mailing Address - Country:US
Mailing Address - Phone:571-215-9808
Mailing Address - Fax:
Practice Address - Street 1:3600 JOSEPH SIEWICK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1709
Practice Address - Country:US
Practice Address - Phone:703-391-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009649183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist