Provider Demographics
NPI:1750796777
Name:SMITH, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 LEONARDTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-3627
Mailing Address - Country:US
Mailing Address - Phone:301-632-5079
Mailing Address - Fax:
Practice Address - Street 1:3855 LEONARDTOWN RD
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-3627
Practice Address - Country:US
Practice Address - Phone:301-632-5079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-28
Last Update Date:2014-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist