MEDICARE: HIGHLANDTOWN PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	P06471	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2148130	OTHER		PK

General Provider Information

NPI Number	:	1033528013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIGHLANDTOWN PHARMACY INC

Provider Business Mailing Address
First Line	:	3911 EASTERN AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21224-4224
Country	:	US
Telephone Number	:	667-212-3621
Fax Number	:	667-212-3623

Provider Business Practice Location Address
First Line	:	3911 EASTERN AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21224-4224
Country	:	US
Telephone Number	:	667-212-3621
Fax Number	:	667-212-3623

Authorized Official
Title or Position	:	MANAGER
Name	:	VINAY KUMAR DASARI
Credential	:
Telephone Number	:	667-212-3621

Provider Enumeration Date	:	08/04/2014
Last Update Date	:	12/13/2016

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