MEDICARE: MR. MICHAEL SCOTT FORMAN BS IN PHARMACY

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	183500000X	Pharmacist	19489	MA
2	183500000X	Pharmacist	RP035829R	PA

General Provider Information

NPI Number	:	1154324556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL SCOTT FORMAN BS IN PHARMACY

Provider Business Mailing Address
First Line	:	7500 SECURITY BLVD
Second Line	:	MAIL STOP: C1-22-06
City	:	BALTIMORE
State	:	MD
Zip	:	21244-1849
Country	:	US
Telephone Number	:	410-786-2666
Fax Number	:	410-786-0486

Provider Business Practice Location Address
First Line	:	7500 SECURITY BLVD
Second Line	:	MAIL STOP: C1-22-06
City	:	BALTIMORE
State	:	MD
Zip	:	21244-1849
Country	:	US
Telephone Number	:	410-786-2666
Fax Number	:	410-786-0486

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	04/11/2013

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