Provider Demographics
NPI:1477937506
Name:HANA PHARMACY ELLICOTT CITY
Entity Type:Organization
Organization Name:HANA PHARMACY ELLICOTT CITY
Other - Org Name:HANA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HEEDO
Authorized Official - Middle Name:
Authorized Official - Last Name:KONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-461-1333
Mailing Address - Street 1:3301 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-7500
Mailing Address - Country:US
Mailing Address - Phone:410-461-1333
Mailing Address - Fax:410-461-1339
Practice Address - Street 1:3301 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-7500
Practice Address - Country:US
Practice Address - Phone:410-461-1333
Practice Address - Fax:410-461-1339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-18
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP069093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD096779300Medicaid