Provider Demographics
NPI:1568854107
Name:FATHIPOUR JALILIAN, MONICA ANAHITA
Entity Type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:ANAHITA
Last Name:FATHIPOUR JALILIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:ANAHITA
Other - Last Name:JODEIRI MIRZAPOUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10301 NEW GUINEA RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-3268
Mailing Address - Country:US
Mailing Address - Phone:703-764-5112
Mailing Address - Fax:
Practice Address - Street 1:10301 NEW GUINEA RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-3268
Practice Address - Country:US
Practice Address - Phone:703-764-5112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230007993183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician