Provider Demographics
NPI:1760596753
Name:KC PHARMACY LLC
Entity Type:Organization
Organization Name:KC PHARMACY LLC
Other - Org Name:KC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FARHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOALEM
Authorized Official - Suffix:
Authorized Official - Credentials:MSME
Authorized Official - Phone:703-339-9599
Mailing Address - Street 1:8988 LORTON STATION BLVD
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-4756
Mailing Address - Country:US
Mailing Address - Phone:703-339-9599
Mailing Address - Fax:703-339-7111
Practice Address - Street 1:8988 LORTON STATION BLVD
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-4756
Practice Address - Country:US
Practice Address - Phone:703-339-9599
Practice Address - Fax:703-339-7111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010040873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4839328OtherNCPDP PROVIDER IDENTIFICATION NUMBER
VA010275776Medicaid
VA010275776Medicaid