Provider Demographics
NPI:1275664104
Name:NEW ERA PHARMACY & VARIETY OUTLET LLC
Entity Type:Organization
Organization Name:NEW ERA PHARMACY & VARIETY OUTLET LLC
Other - Org Name:NEW ERA CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:SELINA NGOZI
Authorized Official - Middle Name:
Authorized Official - Last Name:OKAFOR NWACHUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:301-808-4361
Mailing Address - Street 1:1436 ADDISON RD S
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-4413
Mailing Address - Country:US
Mailing Address - Phone:301-808-4361
Mailing Address - Fax:301-808-5291
Practice Address - Street 1:1436 ADDISON RD S
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-4413
Practice Address - Country:US
Practice Address - Phone:301-808-4361
Practice Address - Fax:301-808-5291
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW ERA PHARMACY & VARIETY OUTLET LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-09
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MDP040413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406032600Medicaid
2037840OtherPK
MD406032600Medicaid