Provider Demographics
NPI:1790139442
Name:REHOBOTH HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:REHOBOTH HEALTHCARE SERVICES
Other - Org Name:OWINGS MILLS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TANON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-352-3818
Mailing Address - Street 1:10085 RED RUN BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4836
Mailing Address - Country:US
Mailing Address - Phone:443-352-3818
Mailing Address - Fax:443-379-0051
Practice Address - Street 1:10085 RED RUN BLVD STE 104
Practice Address - Street 2:SUITE 104
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4811
Practice Address - Country:US
Practice Address - Phone:443-352-3818
Practice Address - Fax:443-379-0051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-19
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336C0004X, 3336L0003X
MDP07055333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159837OtherPK
MD1087894Medicaid