Provider Demographics
NPI:1285667527
Name:GIANT OF MARYLAND LLC
Entity Type:Organization
Organization Name:GIANT OF MARYLAND LLC
Other - Org Name:GIANT PHARMACY 744
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR 3RD PARTY AND MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-380-5609
Mailing Address - Street 1:5740 UNION MILL RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:VA
Mailing Address - Zip Code:20124-1088
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5740 UNION MILL RD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:VA
Practice Address - Zip Code:20124-1088
Practice Address - Country:US
Practice Address - Phone:703-818-0589
Practice Address - Fax:703-818-2707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003063333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008543551Medicaid
4825824OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4825824OtherOTHER ID NUMBER-COMMERCIAL NUMBER