Healthcare Provider Details

I. General information

NPI: 1477558112
Provider Name (Legal Business Name): LAUREL MAIN STREET PHARMACY INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2005
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 MAIN ST
LAUREL MD
20707-4067
US

IV. Provider business mailing address

667 MAIN ST
LAUREL MD
20707-4067
US

V. Phone/Fax

Practice location:
  • Phone: 301-317-3838
  • Fax: 301-317-3637
Mailing address:
  • Phone: 301-317-3838
  • Fax: 301-317-3637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16959
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALI H THAKKAR
Title or Position: OWNER
Credential:
Phone: 301-317-3838