Provider Demographics
NPI:1689607939
Name:GIANT OF MARYLAND LLC
Entity Type:Organization
Organization Name:GIANT OF MARYLAND LLC
Other - Org Name:GIANT PHARMACY 192
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 1:18250 FLOWER HILL WAY
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-5300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18250 FLOWER HILL WAY
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-5300
Practice Address - Country:US
Practice Address - Phone:301-948-1198
Practice Address - Fax:301-926-8640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPO1354333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2114534OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MD695303400Medicaid
MD4081710076Medicare NSC