Provider Demographics
NPI:1518332402
Name:POWELL, CHARLOTTE M
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:M
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 PULASKI HWY
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-2603
Mailing Address - Country:US
Mailing Address - Phone:410-939-2760
Mailing Address - Fax:
Practice Address - Street 1:1031 PULASKI HWY
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-2603
Practice Address - Country:US
Practice Address - Phone:410-939-2760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD428952332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD020787710OtherDURABLE GOODS SUPPLIER