Provider Demographics
NPI:1710618129
Name:ST THEODORE LLC
Entity Type:Organization
Organization Name:ST THEODORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:EHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:TADROUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-367-3914
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:20105-3255
Mailing Address - Country:US
Mailing Address - Phone:571-367-3914
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:20105-3255
Practice Address - Country:US
Practice Address - Phone:571-367-3914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:-
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-17
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1659860500Medicaid