Provider Demographics
NPI:1497041768
Name:ELLICOTT CITY PHARMACY INC
Entity Type:Organization
Organization Name:ELLICOTT CITY PHARMACY INC
Other - Org Name:ELLICOTT CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:NA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:410-750-1951
Mailing Address - Street 1:10194 BALTIMORE NATIONAL PIKE STE 104
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-3655
Mailing Address - Country:US
Mailing Address - Phone:410-750-1951
Mailing Address - Fax:410-750-1953
Practice Address - Street 1:10194 BALTIMORE NATIONAL PIKE STE 104
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3655
Practice Address - Country:US
Practice Address - Phone:410-750-1951
Practice Address - Fax:410-750-1953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-24
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MDP055433336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131136OtherPK
MD442813700Medicaid