Provider Demographics
NPI:1922596691
Name:PROSPERITY PHARMACY MED CENTER INC
Entity Type:Organization
Organization Name:PROSPERITY PHARMACY MED CENTER INC
Other - Org Name:HANN'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:GAITAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-334-5180
Mailing Address - Street 1:8505 ARLINGTON BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4636
Mailing Address - Country:US
Mailing Address - Phone:703-495-3350
Mailing Address - Fax:703-620-3020
Practice Address - Street 1:8505 ARLINGTON BLVD STE 110
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4636
Practice Address - Country:US
Practice Address - Phone:703-495-3350
Practice Address - Fax:703-620-3020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010048363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177251OtherPK