Basic Information
Provider Information | |||||||||
NPI: | 1467839092 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DESTA | ||||||||
FirstName: | BETHEL | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3700 FETTLER PARK DR | ||||||||
Address2: |   | ||||||||
City: | DUMFRIES | ||||||||
State: | VA | ||||||||
PostalCode: | 220252050 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7034417500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 17425 DENALI PL | ||||||||
Address2: |   | ||||||||
City: | DUMFRIES | ||||||||
State: | VA | ||||||||
PostalCode: | 220251967 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7032258655 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2015 | ||||||||
LastUpdateDate: | 05/04/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 0202208257 | VA | Y |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.