Provider Demographics
NPI:1043244205
Name:COVENANT FOOD STORES INC.
Entity Type:Organization
Organization Name:COVENANT FOOD STORES INC.
Other - Org Name:COVENANT PHARMACY/GROCERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:COLLINWISE
Authorized Official - Middle Name:
Authorized Official - Last Name:OSEI-ABOAGYE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:301-362-9100
Mailing Address - Street 1:14633 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4902
Mailing Address - Country:US
Mailing Address - Phone:301-362-9100
Mailing Address - Fax:301-362-9138
Practice Address - Street 1:14633 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4902
Practice Address - Country:US
Practice Address - Phone:301-362-9100
Practice Address - Fax:301-362-9138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP04006183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD00111850Medicaid
MD2127214OtherNCPDP
MD2127214OtherNCPDP