Healthcare Provider Details

I. General information

NPI: 1023955820
Provider Name (Legal Business Name): PATHASHALA100 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HIGH ST
WALDORF MD
20602-1846
US

IV. Provider business mailing address

30 HIGH ST
WALDORF MD
20602-1846
US

V. Phone/Fax

Practice location:
  • Phone: 240-448-3301
  • Fax: 240-448-3302
Mailing address:
  • Phone: 240-448-3301
  • Fax: 240-448-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MANISHKUMAR PATEL
Title or Position: OWNER
Credential: PHARMACY TECHNICIAN
Phone: 248-495-5705