Provider Demographics
NPI:1346347275
Name:MILFORD STREET PHARMACY LLC
Entity Type:Organization
Organization Name:MILFORD STREET PHARMACY LLC
Other - Org Name:MILFORD STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RAYATHATHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-860-0700
Mailing Address - Street 1:106 MILFORD ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804
Mailing Address - Country:US
Mailing Address - Phone:410-860-0700
Mailing Address - Fax:410-860-0079
Practice Address - Street 1:106 MILFORD ST
Practice Address - Street 2:SUITE 401
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-6953
Practice Address - Country:US
Practice Address - Phone:410-860-0700
Practice Address - Fax:410-860-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD401150300Medicaid
MD501304600Medicaid
MD402581400Medicaid
2037547OtherPK