Provider Demographics
NPI:1093750523
Name:ANTIETAM HEALTH SERVICES INC
Entity Type:Organization
Organization Name:ANTIETAM HEALTH SERVICES INC
Other - Org Name:HOME CARE PHARMACY N
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY MGR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SWARNER
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARM
Authorized Official - Phone:240-313-3110
Mailing Address - Street 1:13424 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-2658
Mailing Address - Country:US
Mailing Address - Phone:240-313-3110
Mailing Address - Fax:240-313-3111
Practice Address - Street 1:13424 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2658
Practice Address - Country:US
Practice Address - Phone:240-313-3110
Practice Address - Fax:240-313-3111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP043563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132633OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MD409926500Medicaid