Healthcare Provider Details

I. General information

NPI: 1285667527
Provider Name (Legal Business Name): GIANT OF MARYLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5740 UNION MILL RD
CLIFTON VA
20124-1088
US

IV. Provider business mailing address

5740 UNION MILL RD
CLIFTON VA
20124-1088
US

V. Phone/Fax

Practice location:
  • Phone: 703-818-0589
  • Fax: 703-818-2707
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0201003063
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BOB STONE
Title or Position: DIR 3RD PARTY AND MANAGED CARE
Credential:
Phone: 781-380-5609