Provider Demographics
NPI:1679508634
Name:GIANT OF MARYLAND LLC
Entity Type:Organization
Organization Name:GIANT OF MARYLAND LLC
Other - Org Name:GIANT PHARMACY 317
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-960-5666
Mailing Address - Street 1:1149 HARRISBURG PIKE
Mailing Address - Street 2:THIRD PARTY COORDINATOR
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-1607
Mailing Address - Country:US
Mailing Address - Phone:717-960-8553
Mailing Address - Fax:717-960-1389
Practice Address - Street 1:4624 EDMONDSON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-1407
Practice Address - Country:US
Practice Address - Phone:410-362-1375
Practice Address - Fax:410-534-5190
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AHOLD USA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-11
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPO2279332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122834OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MD125548700Medicaid
2122834OtherOTHER ID NUMBER-COMMERCIAL NUMBER