Healthcare Provider Details

I. General information

NPI: 1386893642
Provider Name (Legal Business Name): EAST PINES PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 03/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6003 66TH AVE
RIVERDALE MD
20737-1780
US

IV. Provider business mailing address

6003 66TH AVE
RIVERDALE MD
20737-1780
US

V. Phone/Fax

Practice location:
  • Phone: 301-459-6211
  • Fax: 301-459-6217
Mailing address:
  • Phone: 301-459-6211
  • Fax: 301-459-6217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP04821
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: OMOTAYO AWOTUNDE
Title or Position: PRESIDENT
Credential:
Phone: 301-459-6211