Provider Demographics
NPI:1093736043
Name:NORTHERN PHCY AT OVERLEA LLC
Entity Type:Organization
Organization Name:NORTHERN PHCY AT OVERLEA LLC
Other - Org Name:NORTHERN PHARMACY AT OVERLEA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND COO
Authorized Official - Prefix:
Authorized Official - First Name:PEPPER
Authorized Official - Middle Name:
Authorized Official - Last Name:MINTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-254-2055
Mailing Address - Street 1:7618 BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4088
Mailing Address - Country:US
Mailing Address - Phone:410-661-1655
Mailing Address - Fax:410-661-1822
Practice Address - Street 1:7618 BELAIR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-4088
Practice Address - Country:US
Practice Address - Phone:410-661-1655
Practice Address - Fax:410-661-1822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MDP041473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2037909OtherPK
MD002883500Medicaid
2037909OtherPK