Provider Demographics
NPI:1669541777
Name:PRIME, INC
Entity type:Organization
Organization Name:PRIME, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:OMOLOLU
Authorized Official - Middle Name:ABIMBOLA
Authorized Official - Last Name:FATUKASI
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:202-399-7876
Mailing Address - Street 1:1647 BENNING RD NE
Mailing Address - Street 2:STE 101
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-4569
Mailing Address - Country:US
Mailing Address - Phone:202-399-7876
Mailing Address - Fax:202-388-3157
Practice Address - Street 1:1647 BENNING RD NE
Practice Address - Street 2:STE 101
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4569
Practice Address - Country:US
Practice Address - Phone:202-399-7876
Practice Address - Fax:202-388-3157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRX02003233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC4850540001Medicare NSC