Provider Demographics
NPI:1982928750
Name:POTOMAC HEALTH PHARMACY LLC
Entity Type:Organization
Organization Name:POTOMAC HEALTH PHARMACY LLC
Other - Org Name:POTOMAC HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AZAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHIMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-595-9610
Mailing Address - Street 1:8142 GILROY DR
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-2936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 OPITZ BLVD
Practice Address - Street 2:STE B
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3320
Practice Address - Country:US
Practice Address - Phone:703-291-0417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010043363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4842173OtherNCPDP PROVIDER IDENTIFICATION NUMBER