Healthcare Provider Details

I. General information

NPI: 1093128522
Provider Name (Legal Business Name): LABORATORYRX OF MARYLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9538 DEERECO RD
TIMONIUM MD
21093-2119
US

IV. Provider business mailing address

60 W TERRA COTTA AVE STE B STE 265
CRYSTAL LAKE IL
60014-3548
US

V. Phone/Fax

Practice location:
  • Phone: 410-916-3070
  • Fax:
Mailing address:
  • Phone: 410-916-3070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. MICHAEL BEATTY
Title or Position: MEMBER
Credential:
Phone: 410-916-3070