Healthcare Provider Details

I. General information

NPI: 1548174154
Provider Name (Legal Business Name): MEDIVANCE SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2009 SAINT THOMAS DR APT 208
WALDORF MD
20602-2175
US

IV. Provider business mailing address

2009 SAINT THOMAS DR APT 208
WALDORF MD
20602-2175
US

V. Phone/Fax

Practice location:
  • Phone: 835-658-9321
  • Fax:
Mailing address:
  • Phone: 835-658-9321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL

VIII. Authorized Official

Name: IMRAN KASHIF
Title or Position: CEO
Credential:
Phone: 835-658-9321