Healthcare Provider Details

I. General information

NPI: 1235482944
Provider Name (Legal Business Name): LAXMI DURGA RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4506 EDMONDSON AVE
BALTIMORE MD
21229-1506
US

IV. Provider business mailing address

4506 EDMONDSON AVE
BALTIMORE MD
21229-1506
US

V. Phone/Fax

Practice location:
  • Phone: 410-566-5565
  • Fax: 410-566-1969
Mailing address:
  • Phone: 410-566-5565
  • Fax: 410-566-1969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberP05769
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. PRUDVI RAM REDDY PEDAVEETI
Title or Position: PHARMACY MANAGER
Credential:
Phone: 410-566-5565