Healthcare Provider Details

I. General information

NPI: 1164598538
Provider Name (Legal Business Name): MEDPARK PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 MEDICAL PKWY SUITE 170
ANNAPOLIS MD
21401-3046
US

IV. Provider business mailing address

2002 MEDICAL PKWY SUITE 170
ANNAPOLIS MD
21401-3046
US

V. Phone/Fax

Practice location:
  • Phone: 410-573-6900
  • Fax:
Mailing address:
  • Phone: 410-573-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP02596
License Number StateMD

VIII. Authorized Official

Name: MR. ROBERT COLLIER ROBERTS
Title or Position: PRESIDENT
Credential: BSP
Phone: 410-573-6900