Provider Demographics
NPI:1760665798
Name:THERIAULT, ALAN PAUL (RPH)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:PAUL
Last Name:THERIAULT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9216 PORTNER AVE
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-5003
Mailing Address - Country:US
Mailing Address - Phone:315-374-0003
Mailing Address - Fax:
Practice Address - Street 1:10110 BATTLEVIEW PKWY STE 100
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2375
Practice Address - Country:US
Practice Address - Phone:712-811-1285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041451183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist