Provider Demographics
NPI:1659300861
Name:CORAM HEALTHCARE CORPORATION OF GREATER DC
Entity Type:Organization
Organization Name:CORAM HEALTHCARE CORPORATION OF GREATER DC
Other - Org Name:CORAM CVS/SPECIALTY INFUSION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LACAVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-306-3255
Mailing Address - Street 1:PO BOX 809160
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-9160
Mailing Address - Country:US
Mailing Address - Phone:480-765-5043
Mailing Address - Fax:401-733-0211
Practice Address - Street 1:7150 COLUMBIA GATEWAY DR
Practice Address - Street 2:SUITE E
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2972
Practice Address - Country:US
Practice Address - Phone:410-720-6501
Practice Address - Fax:410-720-6460
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORAM HEALTHCARE CORPORATION OF GREATER DC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-01
Last Update Date:2023-03-07
Deactivation Date:2023-01-30
Deactivation Code:
Reactivation Date:2023-02-07
Provider Licenses
StateLicense IDTaxonomies
MD1094251E00000X, 251F00000X, 261QI0500X
332B00000X
MDPWO131332BP3500X, 333600000X, 3336C0003X, 3336H0001X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
No251E00000XAgenciesHome Health
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1094OtherRESIDENTIAL SERVICE AGENC
2120323OtherNCPDP
MDPWO131OtherRX LICENSE
MDPWO131OtherRX LICENSE
MD0624590003Medicare NSC
MD1385020 00Medicaid
973RMedicare ID - Type UnspecifiedPART B LOCAL
MD0624590003Medicare NSC