Provider Demographics
NPI:1255438180
Name:INTRADE INC
Entity type:Organization
Organization Name:INTRADE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MANISH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-760-4595
Mailing Address - Street 1:1600 CRAIN HWY S
Mailing Address - Street 2:STE 110
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5577
Mailing Address - Country:US
Mailing Address - Phone:410-760-4595
Mailing Address - Fax:410-760-1575
Practice Address - Street 1:1600 CRAIN HWY S
Practice Address - Street 2:STE 110
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5577
Practice Address - Country:US
Practice Address - Phone:410-760-4595
Practice Address - Fax:410-760-1575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
MDP03144333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000151100Medicaid
2037774OtherPK
5070870001Medicare NSC
5070890001Medicare NSC