Provider Demographics
NPI:1205961489
Name:STATE PHARMACY
Entity type:Organization
Organization Name:STATE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:NKINANG
Authorized Official - Last Name:BIBUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:202-610-2100
Mailing Address - Street 1:2041 MARTIN LUTHER KING AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SE WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020
Mailing Address - Country:US
Mailing Address - Phone:202-610-2100
Mailing Address - Fax:202-610-1078
Practice Address - Street 1:2041 MARTIN LUTHER KING AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SE WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020
Practice Address - Country:US
Practice Address - Phone:202-610-2100
Practice Address - Fax:202-610-1078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRX0300330332B00000X, 3336C0003X
332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC034828700Medicaid
DC035360800Medicaid