Healthcare Provider Details

I. General information

NPI: 1376837658
Provider Name (Legal Business Name): GOVINDAN VAIDYANATHAN R.PH., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2011
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5624 BALTIMORE NATIONAL PIKE RITE AID PHARMACY STORE 374
BALTIMORE MD
21228-1401
US

IV. Provider business mailing address

3324 DEBRA CT
ELLICOTT CITY MD
21042-3699
US

V. Phone/Fax

Practice location:
  • Phone: 410-719-7608
  • Fax:
Mailing address:
  • Phone: 301-340-6956
  • Fax: 301-340-6956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18471
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number18471
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: