Provider Demographics
NPI:1619074549
Name:SUITLAND COMMUNITY PHARMACY
Entity Type:Organization
Organization Name:SUITLAND COMMUNITY PHARMACY
Other - Org Name:SUITLAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-736-3270
Mailing Address - Street 1:4731 A SILVER HILL RD
Mailing Address - Street 2:SUITLAND COMMUNITY PHARMACY
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-2408
Mailing Address - Country:US
Mailing Address - Phone:301-736-3270
Mailing Address - Fax:301-736-3158
Practice Address - Street 1:4731 A SILVER HILL RD
Practice Address - Street 2:SUITLAND COMMUNITY PHARMACY
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746-2408
Practice Address - Country:US
Practice Address - Phone:301-736-3270
Practice Address - Fax:301-736-3158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP07396333600000X
MDP019573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0902180Medicaid
MD258728900Medicaid
MD921340600Medicaid
2036089OtherPK
2036089OtherPK