Provider Demographics
NPI:1972690162
Name:HEREFORD PHARMACY INC
Entity Type:Organization
Organization Name:HEREFORD PHARMACY INC
Other - Org Name:HEREFORD PHARMACY AND GIFT SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:T
Authorized Official - Last Name:PFAFF
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:410-329-6209
Mailing Address - Street 1:216 MOUNT CARMEL RD
Mailing Address - Street 2:
Mailing Address - City:PARKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21120-9725
Mailing Address - Country:US
Mailing Address - Phone:410-329-6209
Mailing Address - Fax:410-357-8002
Practice Address - Street 1:216 MOUNT CARMEL RD
Practice Address - Street 2:
Practice Address - City:PARKTON
Practice Address - State:MD
Practice Address - Zip Code:21120-9725
Practice Address - Country:US
Practice Address - Phone:410-329-6209
Practice Address - Fax:410-357-8002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
MDP015153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD533922700Medicaid
2034346OtherPK
2034346OtherPK