Provider Demographics
NPI:1639267891
Name:GIANT OF MARYLAND LLC
Entity Type:Organization
Organization Name:GIANT OF MARYLAND LLC
Other - Org Name:GIANT PHARMACY #791
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:617-770-8982
Mailing Address - Street 1:1385 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5103
Mailing Address - Country:US
Mailing Address - Phone:401-238-3820
Mailing Address - Fax:401-238-3057
Practice Address - Street 1:43760 GREENWAY CORPOATE DRIVE
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147
Practice Address - Country:US
Practice Address - Phone:401-238-3820
Practice Address - Fax:401-238-3057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA201004105332B00000X
VA02010041053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010324092Medicaid
VA4839467OtherNCPDP
VA4839467OtherNCPDP