Provider Demographics
NPI:1477558112
Name:LAUREL MAIN STREET PHARMACY INCORPORATED
Entity Type:Organization
Organization Name:LAUREL MAIN STREET PHARMACY INCORPORATED
Other - Org Name:MAIN STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:H
Authorized Official - Last Name:THAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-317-3838
Mailing Address - Street 1:667 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4067
Mailing Address - Country:US
Mailing Address - Phone:301-317-3838
Mailing Address - Fax:301-317-3637
Practice Address - Street 1:667 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4067
Practice Address - Country:US
Practice Address - Phone:301-317-3838
Practice Address - Fax:301-317-3637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-18
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16959183500000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0029793Medicaid
MD2132087OtherNCPDP NUMBER