=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326094574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID-ATLANTIC VENTURES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2021 W PRATT ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21223-2242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-566-1360
-----------------------------------------------------
Fax | 410-566-5088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2021 W PRATT ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21223-2242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-566-1360
-----------------------------------------------------
Fax | 410-566-5088
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PHARMACIST MGR.
-----------------------------------------------------
Name | MR. GBENGA ISAAC OLAJIDE
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 410-566-1360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | P03079
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------