Provider Demographics
NPI:1396348694
Name:MOMTAHAN, MAHSA
Entity type:Individual
Prefix:
First Name:MAHSA
Middle Name:
Last Name:MOMTAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43804 CENTRAL STATION DR APT 221
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-7381
Mailing Address - Country:US
Mailing Address - Phone:703-243-4239
Mailing Address - Fax:
Practice Address - Street 1:2121 15TH ST N
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22201-2686
Practice Address - Country:US
Practice Address - Phone:703-243-4239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202217110183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist