Basic Information
| Provider Information | |||||||||
| NPI: | 1700312782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | RAGAN | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | RAGAN | ||||||||
| OtherFirstName: | DIANA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 201 N WASHINGTON ST | ||||||||
| Address2: | PHARMACY | ||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220464518 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 N WASHINGTON ST | ||||||||
| Address2: | PHARMACY | ||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220464518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032374000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2017 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 0202212163 | VA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.