Provider Demographics
NPI:1881128544
Name:AMITY HEALTH INC
Entity type:Organization
Organization Name:AMITY HEALTH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VASUMATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:VANTIKOMMU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-568-2835
Mailing Address - Street 1:42469 NICKENS PL
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-8064
Mailing Address - Country:US
Mailing Address - Phone:703-568-2835
Mailing Address - Fax:
Practice Address - Street 1:9210 CHURCH ST STE 100
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5524
Practice Address - Country:US
Practice Address - Phone:571-357-4818
Practice Address - Fax:703-782-9393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
VA02010047633336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2017136935Medicaid
2168741OtherPK