Provider Demographics
NPI:1275566523
Name:GIANT OF MARYLAND LLC
Entity Type:Organization
Organization Name:GIANT OF MARYLAND LLC
Other - Org Name:SUPER G PHARMACY 386
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, PHARMACY THIRD PARTY
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-240-1526
Mailing Address - Street 1:1149 HARRISBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-1607
Mailing Address - Country:US
Mailing Address - Phone:717-240-5520
Mailing Address - Fax:717-960-8371
Practice Address - Street 1:4301 CONCORD PIKE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-1461
Practice Address - Country:US
Practice Address - Phone:302-475-6572
Practice Address - Fax:302-477-5190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA30000593332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000647507Medicaid
0803228OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0803228OtherOTHER ID NUMBER-COMMERCIAL NUMBER