Provider Demographics
NPI:1679888655
Name:ZONETAK HEALTHCARE AND
Entity Type:Organization
Organization Name:ZONETAK HEALTHCARE AND
Other - Org Name:ZONETAK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:NGUEGNI
Authorized Official - Middle Name:
Authorized Official - Last Name:FOBI-TAKUSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-363-8271
Mailing Address - Street 1:4200 SIHLER OAKS TRL
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5006
Mailing Address - Country:US
Mailing Address - Phone:410-363-8271
Mailing Address - Fax:410-363-8273
Practice Address - Street 1:10085 RED RUN BLVD STE 104
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4811
Practice Address - Country:US
Practice Address - Phone:410-363-8271
Practice Address - Fax:410-363-8273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP053803336C0003X
3336L0003X, 3336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127189OtherPK
2135475OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MD6717190001Medicare NSC