Healthcare Provider Details

I. General information

NPI: 1457394108
Provider Name (Legal Business Name): JOHN WAYNE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9106 PHILADELPHIA RD STE 100
BALTIMORE MD
21237-4329
US

IV. Provider business mailing address

844 RITCHIE HWY STE 208
SEVERNA PARK MD
21146-4137
US

V. Phone/Fax

Practice location:
  • Phone: 410-687-8113
  • Fax: 410-391-3922
Mailing address:
  • Phone: 410-294-3884
  • Fax: 410-544-0774

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 NumberP04404
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN WAYNE
Title or Position: PHARMACIST AND OWNER
Credential: PD
Phone: 410-687-8113