Provider Demographics
NPI:1083629992
Name:MARYLAND GROCERY STORE COMPANY
Entity type:Organization
Organization Name:MARYLAND GROCERY STORE COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAPPELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-463-6200
Mailing Address - Street 1:700 CRANBERRY WOODS DR
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-5213
Mailing Address - Country:US
Mailing Address - Phone:412-963-6200
Mailing Address - Fax:
Practice Address - Street 1:1275 W PATRICK ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4886
Practice Address - Country:US
Practice Address - Phone:301-668-8717
Practice Address - Fax:301-360-0513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP02508333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126224OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MD699375300Medicaid
MD870021414OtherMEDICARE RAILROAD FLU GIANT EAGLE MARYLAND
2126224OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MD106431Medicare PIN