Provider Demographics
NPI:1821364753
Name:CAVANAUGH, CHARLES J
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8120 ELSIES WAY
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-1028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4611 ASSEMBLY DR
Practice Address - Street 2:SUITE H
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4371
Practice Address - Country:US
Practice Address - Phone:240-624-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09329183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist