Provider Demographics
NPI:1326094574
Name:MID-ATLANTIC VENTURES, INC
Entity Type:Organization
Organization Name:MID-ATLANTIC VENTURES, INC
Other - Org Name:WESTSIDE PHARMACY & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST MGR.
Authorized Official - Prefix:MR
Authorized Official - First Name:GBENGA
Authorized Official - Middle Name:ISAAC
Authorized Official - Last Name:OLAJIDE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:410-566-1360
Mailing Address - Street 1:2021 W PRATT ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21223-2242
Mailing Address - Country:US
Mailing Address - Phone:410-566-1360
Mailing Address - Fax:410-566-5088
Practice Address - Street 1:2021 W PRATT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-2242
Practice Address - Country:US
Practice Address - Phone:410-566-1360
Practice Address - Fax:410-566-5088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP030793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDBW8021052OtherDEA NUMBER
MDBW8021052OtherDEA NUMBER