Provider Demographics
NPI:1457475030
Name:BELVEDERE PHARMACY LLC
Entity Type:Organization
Organization Name:BELVEDERE PHARMACY LLC
Other - Org Name:BELVEDERE PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-367-5628
Mailing Address - Street 1:3716 AND ONE HALF W BELVEREDE AVE
Mailing Address - Street 2:UNIT C
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215
Mailing Address - Country:US
Mailing Address - Phone:410-367-5628
Mailing Address - Fax:410-367-5639
Practice Address - Street 1:3716 AND ONE HALF W BELVEREDE AVE
Practice Address - Street 2:UNIT C
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215
Practice Address - Country:US
Practice Address - Phone:410-367-5628
Practice Address - Fax:410-367-5639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336C0004X
MDP045533336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2038225OtherPK
MD014324300Medicaid
MD014324300Medicaid