Healthcare Provider Details

I. General information

NPI: 1235820366
Provider Name (Legal Business Name): MRS. ALISA GOLDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E EAGER ST
BALTIMORE MD
21202-5533
US

IV. Provider business mailing address

1000 E EAGER ST
BALTIMORE MD
21202-5533
US

V. Phone/Fax

Practice location:
  • Phone: 410-675-5696
  • Fax: 410-522-9885
Mailing address:
  • Phone: 410-675-5696
  • Fax: 410-522-9885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT00781
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: