Healthcare Provider Details

I. General information

NPI: 1417264458
Provider Name (Legal Business Name): MT VERNON PHARMACY AT FALLSWAY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 FALLSWAY
BALTIMORE MD
21202-4800
US

IV. Provider business mailing address

900 CATHEDRAL ST
BALTIMORE MD
21201-5311
US

V. Phone/Fax

Practice location:
  • Phone: 410-962-1100
  • Fax: 410-962-1300
Mailing address:
  • Phone: 410-539-8030
  • Fax: 410-539-8115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP05345
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN WIENNER
Title or Position: PRESIDENT
Credential:
Phone: 410-539-8030