Provider Demographics
NPI:1821698705
Name:KEITA, JEAN-ARNAUD MAMOUDOU JOSE (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:JEAN-ARNAUD
Middle Name:MAMOUDOU JOSE
Last Name:KEITA
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PALISADES CIR APT 1225
Mailing Address - Street 2:
Mailing Address - City:MANASSAS PARK
Mailing Address - State:VA
Mailing Address - Zip Code:20111-8058
Mailing Address - Country:US
Mailing Address - Phone:703-870-1214
Mailing Address - Fax:
Practice Address - Street 1:10 RIVERTON COMMONS DR
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-6718
Practice Address - Country:US
Practice Address - Phone:540-635-7712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202214735183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist