Provider Demographics
NPI:1639102981
Name:GIANT OF MARYLAND LLC
Entity Type:Organization
Organization Name:GIANT OF MARYLAND LLC
Other - Org Name:GIANT PHARMACY 252
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:DAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-770-8782
Mailing Address - Street 1:1000 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-3134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132-3134
Practice Address - Country:US
Practice Address - Phone:703-443-6361
Practice Address - Fax:703-443-6390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003918332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010011060Medicaid
4837576OtherOTHER ID NUMBER-COMMERCIAL NUMBER
VA010011060Medicaid