Provider Demographics
NPI:1144767575
Name:CLEVELAND ENTERPRISE II LLC
Entity Type:Organization
Organization Name:CLEVELAND ENTERPRISE II LLC
Other - Org Name:MECMO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-385-0917
Mailing Address - Street 1:5831 ALLENTOWN RD
Mailing Address - Street 2:
Mailing Address - City:CAMP SPRINGS
Mailing Address - State:MD
Mailing Address - Zip Code:20746-4570
Mailing Address - Country:US
Mailing Address - Phone:786-385-0917
Mailing Address - Fax:301-909-0697
Practice Address - Street 1:5831 ALLENTOWN RD
Practice Address - Street 2:
Practice Address - City:CAMP SPRINGS
Practice Address - State:MD
Practice Address - Zip Code:20746-4570
Practice Address - Country:US
Practice Address - Phone:786-385-0917
Practice Address - Fax:301-909-0697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP074423336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2165891OtherPK