Provider Demographics
NPI:1629426648
Name:MY DR'S PHARMACY
Entity Type:Organization
Organization Name:MY DR'S PHARMACY
Other - Org Name:MY DR'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:JAMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:703-215-8000
Mailing Address - Street 1:492 ELDEN ST
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4513
Mailing Address - Country:US
Mailing Address - Phone:703-215-8000
Mailing Address - Fax:703-955-7558
Practice Address - Street 1:492 ELDEN ST
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4513
Practice Address - Country:US
Practice Address - Phone:703-215-8000
Practice Address - Fax:703-955-7558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-31
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X, 333600000X, 3336C0002X
VA02010047083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629426648Medicaid
2160792OtherPK