1639267891 NPI number — GIANT OF MARYLAND LLC

Table of content: (NPI 1639267891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639267891 NPI number — GIANT OF MARYLAND LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GIANT OF MARYLAND LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GIANT PHARMACY #791
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639267891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1385 HANCOCK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUINCY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02169-5103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-238-3820
Provider Business Mailing Address Fax Number:
401-238-3057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43760 GREENWAY CORPOATE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHBURN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-238-3820
Provider Business Practice Location Address Fax Number:
401-238-3057
Provider Enumeration Date:
10/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DAYTON
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
617-770-8982

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  201004105 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 0201004105 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010324092 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4839467 . This is a "NCPDP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".