Provider Demographics
NPI:1417297094
Name:COLUMBIA PHARMACY
Entity Type:Organization
Organization Name:COLUMBIA PHARMACY
Other - Org Name:COLUMBIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:ARASH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:410-995-1111
Mailing Address - Street 1:9650 SANTIAGO RD STE 11
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3960
Mailing Address - Country:US
Mailing Address - Phone:410-995-1111
Mailing Address - Fax:410-995-1112
Practice Address - Street 1:9650 SANTIAGO RD STE 11
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3960
Practice Address - Country:US
Practice Address - Phone:410-995-1111
Practice Address - Fax:410-995-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-19
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP059633336C0003X
MD059633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138937OtherPK
MD443809400Medicaid