Provider Demographics
NPI:1942368162
Name:STATE OF MARYLAND
Entity Type:Organization
Organization Name:STATE OF MARYLAND
Other - Org Name:HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE DIRECTOR, HEALTH CENTER
Authorized Official - Prefix:
Authorized Official - First Name:DEIRDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNGER
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:301-314-9686
Mailing Address - Street 1:CAMPUS DR BLDG 140
Mailing Address - Street 2:UNIVERSITY OF MARYLAND
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20742-0001
Mailing Address - Country:US
Mailing Address - Phone:301-314-8167
Mailing Address - Fax:301-314-3677
Practice Address - Street 1:CAMPUS DR BLDG 140
Practice Address - Street 2:UNIVERSITY OF MARYLAND
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20742-0001
Practice Address - Country:US
Practice Address - Phone:301-314-8167
Practice Address - Fax:301-314-3677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP008453336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD780882800Medicaid
MD780882811Medicaid
2033551OtherPK