Provider Demographics
NPI:1811298979
Name:MASSOUD, REDA (RPH)
Entity type:Individual
Prefix:
First Name:REDA
Middle Name:
Last Name:MASSOUD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12605 BLYTHEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-7286
Mailing Address - Country:US
Mailing Address - Phone:703-222-6062
Mailing Address - Fax:
Practice Address - Street 1:12605 BLYTHEWOOD DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7286
Practice Address - Country:US
Practice Address - Phone:703-222-6062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202007510183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist