Provider Demographics
NPI:1578338273
Name:SHIN, DONGMIN
Entity Type:Individual
Prefix:
First Name:DONGMIN
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12562 SUMMIT MANOR DR APT 303
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-5729
Mailing Address - Country:US
Mailing Address - Phone:508-736-8985
Mailing Address - Fax:
Practice Address - Street 1:13047 FAIR LAKES SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-5179
Practice Address - Country:US
Practice Address - Phone:703-449-8186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH241468183500000X
VA0202221277183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist