Provider Demographics
NPI:1417541632
Name:CYREENE
Entity Type:Organization
Organization Name:CYREENE
Other - Org Name:CYREENE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEAD PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:AIDOO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:301-481-9928
Mailing Address - Street 1:25805 POINT LOOKOUT RD STE C
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2038
Mailing Address - Country:US
Mailing Address - Phone:240-309-4101
Mailing Address - Fax:240-309-4151
Practice Address - Street 1:25805 POINT LOOKOUT RD STE C
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2038
Practice Address - Country:US
Practice Address - Phone:240-309-4101
Practice Address - Fax:240-309-4151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-28
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD692176100Medicaid