=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750032926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHSOURCE DISTRIBUTORS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2022
-----------------------------------------------------
Last Update Date | 01/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7200 RUTHERFORD RD STE 150
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21244-2743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 141-065-3111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7200 RUTHERFORD RD STE 150
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21244-2743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 141-065-3111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JERRY WOLASKY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-653-1113
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------