Provider Demographics
NPI:1790054658
Name:MATHEWS, SUSAN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4725 W OX RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6125
Mailing Address - Country:US
Mailing Address - Phone:703-802-1229
Mailing Address - Fax:703-332-3221
Practice Address - Street 1:4725 W OX RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6125
Practice Address - Country:US
Practice Address - Phone:703-802-1229
Practice Address - Fax:703-332-3221
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204402818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202204402818OtherVIRGINIA BOARD OF PHARMACY LICENSE NUMBER