Provider Demographics
NPI:1720582893
Name:MARYLAND SPECIALTY AND COMPOUNDING PHARMACY LLC
Entity Type:Organization
Organization Name:MARYLAND SPECIALTY AND COMPOUNDING PHARMACY LLC
Other - Org Name:PROFESSIONAL ARTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THAI
Authorized Official - Middle Name:
Authorized Official - Last Name:HUYNH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:404-514-2016
Mailing Address - Street 1:3138 ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3320
Mailing Address - Country:US
Mailing Address - Phone:443-200-1200
Mailing Address - Fax:443-252-8093
Practice Address - Street 1:3138 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3320
Practice Address - Country:US
Practice Address - Phone:443-200-1200
Practice Address - Fax:443-252-8093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-22
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336S0011X
MDP077183336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2142379OtherNCPDP NUMBER
MD543121200Medicaid
MD1720582893OtherNPI
2176312OtherPK