Provider Demographics
NPI:1184657439
Name:GIANT OF MARYLAND LLC
Entity Type:Organization
Organization Name:GIANT OF MARYLAND LLC
Other - Org Name:SUPER G PHARMACY 387
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-885-7454
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:MS 3000
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5005
Mailing Address - Country:US
Mailing Address - Phone:207-885-7454
Mailing Address - Fax:704-645-6531
Practice Address - Street 1:19312 LIGHTHOUSE PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971
Practice Address - Country:US
Practice Address - Phone:302-227-5954
Practice Address - Fax:302-226-6190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA30000654332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0803634OtherOTHER ID NUMBER-COMMERCIAL NUMBER
DE0000923207Medicaid
DE0000923207Medicaid