Provider Demographics
NPI:1720697436
Name:GOPHER WOOD CORP
Entity Type:Organization
Organization Name:GOPHER WOOD CORP
Other - Org Name:MAXCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUJIMI
Authorized Official - Middle Name:
Authorized Official - Last Name:BABATUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:DR, RPH
Authorized Official - Phone:410-553-4137
Mailing Address - Street 1:7448 BALTIMORE ANNAPOLIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3468
Mailing Address - Country:US
Mailing Address - Phone:410-553-4137
Mailing Address - Fax:410-487-6142
Practice Address - Street 1:7448 BALTIMORE ANNAPOLIS BLVD STE A
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3468
Practice Address - Country:US
Practice Address - Phone:410-553-4137
Practice Address - Fax:410-487-6142
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOPHER WOOD CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-28
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD166752100Medicaid