Provider Demographics
NPI:1699219980
Name:ADVENTIST HEALTHCARE INC
Entity Type:Organization
Organization Name:ADVENTIST HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-244-4813
Mailing Address - Street 1:7600 CARROLL AVE
Mailing Address - Street 2:OUTPATIENT PHARMACY
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6367
Mailing Address - Country:US
Mailing Address - Phone:301-891-6625
Mailing Address - Fax:
Practice Address - Street 1:7600 CARROLL AVE
Practice Address - Street 2:OUTPATIENT PHARMACY
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6367
Practice Address - Country:US
Practice Address - Phone:301-891-6625
Practice Address - Fax:301-891-6208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP074173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD117082100Medicaid
2166611OtherPK