=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659764181
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | APOLLO PHARMACY OF GAITHERSBURG, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2015
-----------------------------------------------------
Last Update Date | 08/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9999 STEDWICK ROAD
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20886-3709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-912-7784
-----------------------------------------------------
Fax | 240-912-7764
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22492 CASTLE OAK ROAD
-----------------------------------------------------
City | CLARKSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20871-5352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-912-7784
-----------------------------------------------------
Fax | 240-912-7764
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE-PRESIDENT
-----------------------------------------------------
Name | MR. UTKARSH DESAI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 240-912-7784
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | P06646
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | P07896
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number | P07896
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | P07896
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------