Healthcare Provider Details

I. General information

NPI: 1104160712
Provider Name (Legal Business Name): HANSON PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 CRAIN HWY
WALDORF MD
20601-3146
US

IV. Provider business mailing address

501 HARRY S TRUMAN DR
UPPER MARLBORO MD
20774-2060
US

V. Phone/Fax

Practice location:
  • Phone: 301-885-0430
  • Fax:
Mailing address:
  • Phone: 301-233-4542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberP05807
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP05807
License Number StateMD

VIII. Authorized Official

Name: DR. KWAME HANSON
Title or Position: PRESIDENT
Credential:
Phone: 301-233-4542