1083711915 NPI number — PATTERSON PARK PHARMACY INC

Table of content: (NPI 1083711915)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083711915 NPI number — PATTERSON PARK PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATTERSON PARK PHARMACY INC
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:
Provider Other Organization Name Type Code:
6
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:
1083711915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2245 EASTERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21231-3113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-675-6046
Provider Business Mailing Address Fax Number:
410-563-1147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2245 EASTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21231-3113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-675-6046
Provider Business Practice Location Address Fax Number:
410-563-1147
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAM
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY DIRECTOR
Authorized Official Telephone Number:
410-675-6046

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: P01066 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2112770 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 333972600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com