MEDICARE: INDEPENDENT DRUG IMMUNIZATION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	P04009	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104238427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT DRUG IMMUNIZATION LLC

Provider Business Mailing Address
First Line	:	28 KINGSTON RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21220-4814
Country	:	US
Telephone Number	:	410-687-1115
Fax Number	:	410-687-0032

Provider Business Practice Location Address
First Line	:	28 KINGSTON RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21220-4814
Country	:	US
Telephone Number	:	410-687-1115
Fax Number	:	410-687-0032

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GEORGE GARMER
Credential	:
Telephone Number	:	410-207-5751

Provider Enumeration Date	:	05/21/2014
Last Update Date	:	05/21/2014

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