Provider Demographics
NPI:1780404038
Name:MCCULLOUGH, DAWN (CPHT)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9766 MATZON RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-1722
Mailing Address - Country:US
Mailing Address - Phone:410-983-1721
Mailing Address - Fax:
Practice Address - Street 1:6701 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21234-7721
Practice Address - Country:US
Practice Address - Phone:443-909-7899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT02960183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician