=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811920168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GIANT OF MARYLAND LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 10/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 WORTH AVE
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22556-1538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-657-5007
-----------------------------------------------------
Fax | 540-657-5009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 317 WORTH AVE
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22556-1538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | BRAD DAYTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-770-8782
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 0201003808
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 0201003808
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 0201003808
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------