Provider Demographics
NPI:1801171020
Name:TAK, CHARLENE
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:TAK
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 1:1930 PULASKI HWY
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-1612
Mailing Address - Country:US
Mailing Address - Phone:410-671-6568
Mailing Address - Fax:410-676-2648
Practice Address - Street 1:1930 PULASKI HWY
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:MD
Practice Address - Zip Code:21040-1612
Practice Address - Country:US
Practice Address - Phone:410-671-6568
Practice Address - Fax:410-676-2648
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18349183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist