Healthcare Provider Details

I. General information

NPI: 1972852812
Provider Name (Legal Business Name): SHALOM PHARMACY AND MEDICAL SUPPLIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8981 WOODYARD RD
CLINTON MD
20735-4203
US

IV. Provider business mailing address

8981 WOODYARD RD
CLINTON MD
20735-4203
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-4094
  • Fax: 301-868-4049
Mailing address:
  • Phone: 301-868-4094
  • Fax: 301-868-4049

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 Number05901
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AYODELE AREWA
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 301-868-4094