Provider Demographics
NPI:1689616112
Name:JOPPA ROAD PHARMACY LLC
Entity Type:Organization
Organization Name:JOPPA ROAD PHARMACY LLC
Other - Org Name:JOPPA ROAD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:410-665-5050
Mailing Address - Street 1:1907A E JOPPA RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21234
Mailing Address - Country:US
Mailing Address - Phone:410-665-5050
Mailing Address - Fax:410-665-5959
Practice Address - Street 1:1907A E JOPPA RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21234
Practice Address - Country:US
Practice Address - Phone:410-665-5050
Practice Address - Fax:410-665-5959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MDP055063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2037999OtherPK
MD4080360Medicaid
MD4086376Medicaid