Provider Demographics
NPI:1952902207
Name:FULAMBARKAR, PRAJAKTA AMOL
Entity Type:Individual
Prefix:
First Name:PRAJAKTA
Middle Name:AMOL
Last Name:FULAMBARKAR
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 1:22440 CONSERVANCY DR
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-8065
Mailing Address - Country:US
Mailing Address - Phone:703-297-9703
Mailing Address - Fax:
Practice Address - Street 1:19360 COMPASS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-5445
Practice Address - Country:US
Practice Address - Phone:703-779-0164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202209060183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist