Healthcare Provider Details

I. General information

NPI: 1104627504
Provider Name (Legal Business Name): OM VIRISSAR PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8186 LARK BROWN RD STE 101
ELKRIDGE MD
21075-6437
US

IV. Provider business mailing address

8186 LARK BROWN RD STE 101
ELKRIDGE MD
21075-6437
US

V. Phone/Fax

Practice location:
  • Phone: 443-620-9990
  • Fax:
Mailing address:
  • Phone: 443-620-9990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. EMMANUEL NDE
Title or Position: MANAGER
Credential: PHARMD
Phone: 571-365-1833