Provider Demographics
NPI:1659860500
Name:ST THEODORE LLC
Entity Type:Organization
Organization Name:ST THEODORE LLC
Other - Org Name:TED PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ESTER
Authorized Official - Middle Name:
Authorized Official - Last Name:TADROUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-358-9201
Mailing Address - Street 1:24585 STONE CARVER DR STE 175
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-2798
Mailing Address - Country:US
Mailing Address - Phone:571-367-3206
Mailing Address - Fax:
Practice Address - Street 1:24585 STONE CARVER DR STE 175
Practice Address - Street 2:
Practice Address - City:ALDIE
Practice Address - State:VA
Practice Address - Zip Code:20105-2798
Practice Address - Country:US
Practice Address - Phone:571-367-3206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3336C0003X
VA02010048443336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA81-322728OtherEIN NUMBER