MEDICARE: GIANT OF MARYLAND 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	333600000X	Pharmacy	0201003042	VA
2	332B00000X	Durable Medical Equipment & Medical Supplies	0201003042	VA
3	3336C0003X	Community/Retail Pharmacy	0201003042	VA

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
2	4814845	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1750314092
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GIANT OF MARYLAND LLC

Provider Business Mailing Address
First Line	:	4309 DALE BLVD
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-2401
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4309 DALE BLVD
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-2401
Country	:	US
Telephone Number	:	703-670-6179
Fax Number	:	703-670-8273

Authorized Official
Title or Position	:	DIRECTOR
Name	:	BRAD DAYTON
Credential	:
Telephone Number	:	617-770-8782

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	10/28/2011

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Directions to “GIANT OF MARYLAND LLC ” Practice Location

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