Provider Demographics
NPI:1356489348
Name:OLD LINE HEALTHCARE INC
Entity Type:Organization
Organization Name:OLD LINE HEALTHCARE INC
Other - Org Name:POTOMAC PHARMATECH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:717-848-3445
Mailing Address - Street 1:16107A ELLIOTT PKWY
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:MD
Mailing Address - Zip Code:21795-4084
Mailing Address - Country:US
Mailing Address - Phone:301-223-6616
Mailing Address - Fax:301-223-6679
Practice Address - Street 1:16107A ELLIOTT PKWY
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:MD
Practice Address - Zip Code:21795-4084
Practice Address - Country:US
Practice Address - Phone:301-223-6616
Practice Address - Fax:301-223-6679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVMO0560293333600000X
MDPW02963336L0003X
3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810023127Medicaid
PA1023189160001Medicaid
MD012478800Medicaid
2038215OtherPK