=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982156246
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE CARE PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2016
-----------------------------------------------------
Last Update Date | 11/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1631 W NORTH AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21217-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-873-8294
-----------------------------------------------------
Fax | 443-873-8413
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1631 W NORTH AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21217-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-873-8294
-----------------------------------------------------
Fax | 443-873-8413
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST/OWNER
-----------------------------------------------------
Name | OKWUCHI OBASI
-----------------------------------------------------
Credential | PHARM. D
-----------------------------------------------------
Telephone | 240-678-2804
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | P07231
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------