Provider Demographics
NPI:1073895413
Name:EXPO E MART, LLC
Entity Type:Organization
Organization Name:EXPO E MART, LLC
Other - Org Name:EXPO E MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:F
Authorized Official - Last Name:DELYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-304-4342
Mailing Address - Street 1:1101 UNIVERSITY BLVD.EAST
Mailing Address - Street 2:SUITE 1350
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6207
Mailing Address - Country:US
Mailing Address - Phone:703-304-4342
Mailing Address - Fax:
Practice Address - Street 1:1101 UNIVERSITY BLVD
Practice Address - Street 2:EXPO E MART PHARMACY
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:301-431-1151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP051153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP05115OtherDHMH, STATE PHARMACY PERMIT