Healthcare Provider Details

I. General information

NPI: 1720185218
Provider Name (Legal Business Name): REA AND DERICK INC P 1835
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 BUCKEYSTOWN PK FRCS SCT KEY MALL
FREDERICK MD
21703
US

IV. Provider business mailing address

1 CVS DR PO BOX 1075
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 301-662-8606
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberP01188
License Number StateMD

VIII. Authorized Official

Name: CRISTIANA MAURICIO
Title or Position: MGR PHCY ENROLLMENTS
Credential:
Phone: 401-770-2937