Provider Demographics
NPI:1255738076
Name:PROSPERITY RX FAIRFAX INC
Entity type:Organization
Organization Name:PROSPERITY RX FAIRFAX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:ODEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-517-4779
Mailing Address - Street 1:2740 PROSPERITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4353
Mailing Address - Country:US
Mailing Address - Phone:703-334-5180
Mailing Address - Fax:703-620-2030
Practice Address - Street 1:2740 PROSPERITY AVE STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4354
Practice Address - Country:US
Practice Address - Phone:703-334-5180
Practice Address - Fax:703-620-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010046173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147267OtherPK