Provider Demographics
NPI:1083711915
Name:PATTERSON PARK PHARMACY INC
Entity Type:Organization
Organization Name:PATTERSON PARK PHARMACY INC
Other - Org Name:PATTERSON PARK PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:410-675-6046
Mailing Address - Street 1:2245 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-3113
Mailing Address - Country:US
Mailing Address - Phone:410-675-6046
Mailing Address - Fax:410-563-1147
Practice Address - Street 1:2245 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-3113
Practice Address - Country:US
Practice Address - Phone:410-675-6046
Practice Address - Fax:410-563-1147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP010663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2112770OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MD333972600Medicaid
MD333972600Medicaid