Provider Demographics
NPI:1821170614
Name:VD & SR PHARMACY LLC
Entity Type:Organization
Organization Name:VD & SR PHARMACY LLC
Other - Org Name:PARK AVENUE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:POTLURI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:443-823-3350
Mailing Address - Street 1:1535 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-4280
Mailing Address - Country:US
Mailing Address - Phone:410-225-0800
Mailing Address - Fax:410-523-3434
Practice Address - Street 1:1535 PARK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-4280
Practice Address - Country:US
Practice Address - Phone:410-225-0800
Practice Address - Fax:410-523-3434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
MDP067083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD991042600Medicaid
2150056OtherPK
MD135502300Medicaid