1578558839 NPI number — OM VIRISAAR PHARMACY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578558839 NPI number — OM VIRISAAR PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OM VIRISAAR 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:
1578558839
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8186 LARK BROWN RD
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
ELKRIDGE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-620-9990
Provider Business Mailing Address Fax Number:
443-620-9993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8186 LARK BROWN RD
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
ELKRIDGE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21075-6433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-620-9990
Provider Business Practice Location Address Fax Number:
443-620-9993
Provider Enumeration Date:
09/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BRAHMANAPALLI
Authorized Official First Name:
RAJKAMAL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/TREASURER
Authorized Official Telephone Number:
443-620-9990

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: P05365 , 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: 2126099 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 420115900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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