Organization
AMITY HEALTH INC
Active
Other names
BULL RUN PROFESSIONAL PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
VASUMATHI VANTIKOMMU (PHARMACY OWNER/MANAGER)
(703) 568-2835
Entity
Organization
Contact information
Practice address
9210 CHURCH ST STE 100, MANASSAS, VA 20110-5524
(571) 357-4818
(703) 782-9393
Mailing address
42469 NICKENS PL, ASHBURN, VA 20148-8064
(703) 568-2835
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
0201004763
VA
3336C0003X
Community/Retail Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2017136935
—
VA
01
—
2168741
PK
—
Enumeration date
04/19/2017
Last updated
12/08/2021
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