Provider Demographics
NPI:1750324083
Name:MEDICAL FACULTY ASSOCIATES INC
Entity type:Organization
Organization Name:MEDICAL FACULTY ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:202-741-2218
Mailing Address - Street 1:2150 PENNSYLVANIA AVE NW
Mailing Address - Street 2:# G201
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-3201
Mailing Address - Country:US
Mailing Address - Phone:202-741-3600
Mailing Address - Fax:202-741-3606
Practice Address - Street 1:2150 PENNSYLVANIA AVE NW
Practice Address - Street 2:# G201
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-3201
Practice Address - Country:US
Practice Address - Phone:202-741-3600
Practice Address - Fax:202-741-3606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336S0011X
DCRX00003013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2004579OtherPK
DC0911970Medicaid