Healthcare Provider Details

I. General information

NPI: 1730720624
Provider Name (Legal Business Name): TIDEWATER DRUG AND HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30170 THREE NOTCH RD UNIT B
CHARLOTTE HALL MD
20622-4119
US

IV. Provider business mailing address

30170 THREE NOTCH RD UNIT B
CHARLOTTE HALL MD
20622-4119
US

V. Phone/Fax

Practice location:
  • Phone: 301-472-1720
  • Fax: 301-472-1719
Mailing address:
  • Phone: 301-472-1720
  • Fax: 301-472-1719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK BARBINO
Title or Position: PHARMACY MANAGER
Credential: PHARMD
Phone: 240-419-7245