Healthcare Provider Details

I. General information

NPI: 1083629992
Provider Name (Legal Business Name): MARYLAND GROCERY STORE COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 W PATRICK ST
FREDERICK MD
21702-4886
US

IV. Provider business mailing address

700 CRANBERRY WOODS DR
CRANBERRY TOWNSHIP PA
16066-5213
US

V. Phone/Fax

Practice location:
  • Phone: 301-668-8717
  • Fax: 301-360-0513
Mailing address:
  • Phone: 412-963-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberP02508
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL CHAPPELL
Title or Position: VP OF PHARMACY
Credential:
Phone: 412-463-6200