Provider Demographics
NPI:1336113463
Name:LEISURE WORLD OF MD CORP
Entity Type:Organization
Organization Name:LEISURE WORLD OF MD CORP
Other - Org Name:LEISURE WORLD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRONAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:301-598-1550
Mailing Address - Street 1:3305 N LEISURE WORLD BLVD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-1367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3305 N LEISURE WORLD BLVD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-1367
Practice Address - Country:US
Practice Address - Phone:301-598-1005
Practice Address - Fax:301-598-1548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP01564333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2111172OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0746160001Medicare ID - Type Unspecified