Healthcare Provider Details

I. General information

NPI: 1679570253
Provider Name (Legal Business Name): NORTHGATE PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3973 SAINT CHARLES PKWY
WALDORF MD
20602-2683
US

IV. Provider business mailing address

3973 SAINT CHARLES PKWY
WALDORF MD
20602-2683
US

V. Phone/Fax

Practice location:
  • Phone: 301-932-7977
  • Fax: 301-932-9373
Mailing address:
  • Phone: 301-932-7977
  • Fax: 301-932-9373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberP04037
License Number StateMD

VIII. Authorized Official

Name: MR. VINCENT IPPOLITO
Title or Position: PHARMACIST/PRESIDENT
Credential: RPH
Phone: 301-932-7977