Provider Demographics
NPI:1902042054
Name:TYSONS PHARMACY INC
Entity Type:Organization
Organization Name:TYSONS PHARMACY INC
Other - Org Name:TYSONS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BIJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMADI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:571-338-3502
Mailing Address - Street 1:110 PLEASANT ST NW
Mailing Address - Street 2:UNIT C
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4447
Mailing Address - Country:US
Mailing Address - Phone:703-992-7083
Mailing Address - Fax:703-992-7253
Practice Address - Street 1:110 PLEASANT ST NW UNIT C
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4447
Practice Address - Country:US
Practice Address - Phone:703-992-7083
Practice Address - Fax:703-992-7253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-19
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336C0004X, 3336L0003X, 3336M0002X, 3336M0003X, 3336S0011X
VA02010043093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121331OtherPK