Provider Demographics
NPI:1720363864
Name:MCKINNON, WADE LEWIS JR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:LEWIS
Last Name:MCKINNON
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:42820 CREEK VIEW PLZ
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-4036
Mailing Address - Country:US
Mailing Address - Phone:703-259-6683
Mailing Address - Fax:703-259-6689
Practice Address - Street 1:42820 CREEK VIEW PLZ
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-4036
Practice Address - Country:US
Practice Address - Phone:703-259-6683
Practice Address - Fax:703-259-6689
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202005202183500000X
FLPS46607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist