Provider Demographics
NPI:1922699768
Name:SHENOUDA, MINA
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:SHENOUDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25619 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-6129
Mailing Address - Country:US
Mailing Address - Phone:703-577-3948
Mailing Address - Fax:
Practice Address - Street 1:14391 CHANTILLY CROSSING LN
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-2118
Practice Address - Country:US
Practice Address - Phone:571-262-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202218571183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist