Healthcare Provider Details

I. General information

NPI: 1255058731
Provider Name (Legal Business Name): MAXWELL SCOTT DITLEVSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 10/25/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E EAGER ST
BALTIMORE MD
21202-5533
US

IV. Provider business mailing address

600 N WOLFE ST CARNEGIE 180
BALTIMORE MD
21287
US

V. Phone/Fax

Practice location:
  • Phone: 410-522-9800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number25852
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: