=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457999229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CYREENE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2019
-----------------------------------------------------
Last Update Date | 04/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25805 POINT LOOKOUT RD
-----------------------------------------------------
City | LEONARDTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20650-2013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-309-4101
-----------------------------------------------------
Fax | 240-309-4094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43944 SWIFT FOX DR
-----------------------------------------------------
City | CALIFORNIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20619-7136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-481-9928
-----------------------------------------------------
Fax | 301-263-7925
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LEAD PHARMACIST
-----------------------------------------------------
Name | MR. DOMINIC AIDOO
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 301-481-9928
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------