Provider Demographics
NPI:1922105840
Name:CHARLESMEAD FOUNTAIN PHARMCY LLC
Entity Type:Organization
Organization Name:CHARLESMEAD FOUNTAIN PHARMCY LLC
Other - Org Name:CHARLESMEAD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:KROMSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-823-1818
Mailing Address - Street 1:6240 BELLONA AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-2408
Mailing Address - Country:US
Mailing Address - Phone:410-435-0210
Mailing Address - Fax:410-323-5025
Practice Address - Street 1:6242 BELLONA AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-2445
Practice Address - Country:US
Practice Address - Phone:410-435-0210
Practice Address - Fax:410-323-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP069643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD547107900Medicaid
2154754OtherPK
2032956OtherPK