Provider Demographics
NPI:1750109138
Name:KEROLUS, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:KEROLUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3327 CONNECTICUT AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-1302
Mailing Address - Country:US
Mailing Address - Phone:213-249-0567
Mailing Address - Fax:
Practice Address - Street 1:6004 WESTCHESTER ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-1124
Practice Address - Country:US
Practice Address - Phone:213-249-0567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPH100003209183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist