Provider Demographics
NPI:1417264458
Name:MT VERNON PHARMACY AT FALLSWAY INC
Entity Type:Organization
Organization Name:MT VERNON PHARMACY AT FALLSWAY INC
Other - Org Name:MT. VERNON PHARMACY AT FALLSWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIENNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-539-8030
Mailing Address - Street 1:900 CATHEDRAL ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5311
Mailing Address - Country:US
Mailing Address - Phone:410-539-8030
Mailing Address - Fax:410-539-8115
Practice Address - Street 1:421 FALLSWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-4800
Practice Address - Country:US
Practice Address - Phone:410-962-1100
Practice Address - Fax:410-962-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
MDP053453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD03625-8100Medicaid
2126651OtherPK
2135413OtherNCPDP PROVIDER IDENTIFICATION NUMBER
208979OtherMEDICARE MASS IMMUNIZER PTAN
MD03625-8100Medicaid