Provider Demographics
NPI:1023058690
Name:LAUREL MAIN STREET PHARMACY INCORPORATED
Entity type:Organization
Organization Name:LAUREL MAIN STREET PHARMACY INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:H
Authorized Official - Last Name:THAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM-D
Authorized Official - Phone:301-317-3838
Mailing Address - Street 1:667 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4067
Mailing Address - Country:US
Mailing Address - Phone:301-317-3838
Mailing Address - Fax:301-317-3637
Practice Address - Street 1:667 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4067
Practice Address - Country:US
Practice Address - Phone:301-317-3838
Practice Address - Fax:301-317-3637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 261QP2300X, 332B00000X, 3336C0002X
MDP058923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0029793Medicaid
MD4097696Medicaid
MD5475220001Medicare NSC