Provider Demographics
NPI:1215015722
Name:JARRETTSVILLE PHARMACY INC
Entity Type:Organization
Organization Name:JARRETTSVILLE PHARMACY INC
Other - Org Name:JARRETTSVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LAPOURAILLE
Authorized Official - Suffix:
Authorized Official - Credentials:BSPHARM
Authorized Official - Phone:410-557-7717
Mailing Address - Street 1:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:JARRETTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21084-0057
Mailing Address - Country:US
Mailing Address - Phone:410-557-7717
Mailing Address - Fax:410-557-4336
Practice Address - Street 1:3714 NORRISVILLE RD
Practice Address - Street 2:
Practice Address - City:JARRETTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21084-1419
Practice Address - Country:US
Practice Address - Phone:410-557-7717
Practice Address - Fax:410-557-4336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP003553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2033059OtherPK
MD142122100Medicaid
MD142122100Medicaid