Provider Demographics
NPI:1942570601
Name:ZONETAK HEALTHCARE
Entity Type:Organization
Organization Name:ZONETAK HEALTHCARE
Other - Org Name:ZONETAK COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:NGUEGNI
Authorized Official - Middle Name:
Authorized Official - Last Name:FOBI-TAKUSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-363-8271
Mailing Address - Street 1:515 FAIRMOUNT AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-8520
Mailing Address - Country:US
Mailing Address - Phone:410-363-8271
Mailing Address - Fax:410-363-8273
Practice Address - Street 1:515 FAIRMOUNT AVE STE 130
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-8520
Practice Address - Country:US
Practice Address - Phone:410-363-8271
Practice Address - Fax:410-363-8273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-11
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X, 3336S0011X
MDP056483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133401OtherPK
MD051732100Medicaid