Provider Demographics
NPI:1942372735
Name:MARELAINE INC
Entity Type:Organization
Organization Name:MARELAINE INC
Other - Org Name:INDEPENDENT DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,RPH,AO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARMER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:410-687-1115
Mailing Address - Street 1:28 KINGSTON RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-4814
Mailing Address - Country:US
Mailing Address - Phone:410-687-1115
Mailing Address - Fax:410-687-0032
Practice Address - Street 1:28 KINGSTON RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21220-4814
Practice Address - Country:US
Practice Address - Phone:410-687-1115
Practice Address - Fax:410-687-0032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
MDP040093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404088100Medicaid
MD405657400Medicaid
2037802OtherPK
MD404088100Medicaid
MD405657400Medicaid