Provider Demographics
NPI:1487105508
Name:MENA, AMIR PAUL
Entity type:Individual
Prefix:
First Name:AMIR
Middle Name:PAUL
Last Name:MENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:
Other - Last Name:MENA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:4300 BACKLICK RD
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-3142
Mailing Address - Country:US
Mailing Address - Phone:703-817-6050
Mailing Address - Fax:703-813-6056
Practice Address - Street 1:4300 BACKLICK RD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3142
Practice Address - Country:US
Practice Address - Phone:703-817-6050
Practice Address - Fax:703-813-6056
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202212592183500000X
FLPS41955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist