Provider Demographics
NPI:1740379429
Name:TUXEDO PHARMACY INC
Entity Type:Organization
Organization Name:TUXEDO PHARMACY INC
Other - Org Name:TUXEDO PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:ARNOLD
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-323-3000
Mailing Address - Street 1:5115 ROLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210
Mailing Address - Country:US
Mailing Address - Phone:410-323-3000
Mailing Address - Fax:410-435-6733
Practice Address - Street 1:5115 ROLAND AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2138
Practice Address - Country:US
Practice Address - Phone:410-323-3000
Practice Address - Fax:410-435-6733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP007943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD079742100Medicaid
2033031OtherPK