Provider Demographics
NPI:1013026640
Name:GIANT OF MARYLAND LLC
Entity Type:Organization
Organization Name:GIANT OF MARYLAND LLC
Other - Org Name:GIANT PHARMACY #790
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR THIRD PARTY
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-770-6257
Mailing Address - Street 1:185 CAMPANELLI DR
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184
Mailing Address - Country:US
Mailing Address - Phone:781-380-5611
Mailing Address - Fax:781-380-5617
Practice Address - Street 1:5581 MERCHANTS VIEW SQUARE
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169
Practice Address - Country:US
Practice Address - Phone:571-248-4551
Practice Address - Fax:571-248-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201004106332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4839467OtherNCPDP
VA010328471Medicaid
VA010328471Medicaid