Provider Demographics
NPI:1831235449
Name:MODSTEL LLC
Entity type:Organization
Organization Name:MODSTEL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLUTAYO
Authorized Official - Middle Name:A
Authorized Official - Last Name:OLUWABUSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-937-6662
Mailing Address - Street 1:10820 RHODE ISLAND AVENUE
Mailing Address - Street 2:SUITE F
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705
Mailing Address - Country:US
Mailing Address - Phone:301-937-6662
Mailing Address - Fax:301-595-0947
Practice Address - Street 1:10820 RHODE ISLAND AVENUE
Practice Address - Street 2:SUITE F
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705
Practice Address - Country:US
Practice Address - Phone:301-937-6662
Practice Address - Fax:301-595-0947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP01780333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD987474700Medicaid
2119166OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2119166OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MDBT8563404OtherDEA #
MD987474700Medicaid