Provider Demographics
NPI:1750595583
Name:CARSON, REGINA (PD MBA)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:PD MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3827 JANBROOK ROAD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133
Mailing Address - Country:US
Mailing Address - Phone:410-521-5734
Mailing Address - Fax:410-521-5875
Practice Address - Street 1:3827 JANBROOK ROAD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133
Practice Address - Country:US
Practice Address - Phone:410-521-5734
Practice Address - Fax:410-521-5875
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD8431183500000X
DCPHA22465183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist