Healthcare Provider Details

I. General information

NPI: 1255438180
Provider Name (Legal Business Name): INTRADE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 CRAIN HWY S STE 110
GLEN BURNIE MD
21061-5577
US

IV. Provider business mailing address

1600 CRAIN HWY S STE 110
GLEN BURNIE MD
21061-5577
US

V. Phone/Fax

Practice location:
  • Phone: 410-760-4595
  • Fax: 410-760-1575
Mailing address:
  • Phone: 410-760-4595
  • Fax: 410-760-1575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberP03144
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MANISH SHAH
Title or Position: OWNER PHARMACIST
Credential:
Phone: 410-760-4595