Provider Demographics
NPI:1881830453
Name:MENLO PHARMACY
Entity Type:Organization
Organization Name:MENLO PHARMACY
Other - Org Name:MENLO PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICO
Authorized Official - Middle Name:
Authorized Official - Last Name:MAWUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-926-3219
Mailing Address - Street 1:17021 OAK HILL RD
Mailing Address - Street 2:
Mailing Address - City:SPENCERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20868-3105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5900 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-3481
Practice Address - Country:US
Practice Address - Phone:410-764-1112
Practice Address - Fax:410-764-1113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-01
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
MDP049633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134334OtherNCPDP PROVIDER IDENTIFICATION NUMBER