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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X0202208257VAY Pharmacy Service ProvidersPharmacist 

No ID Information.


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