Provider Demographics
NPI:1104238427
Name:INDEPENDENT DRUG IMMUNIZATION LLC
Entity type:Organization
Organization Name:INDEPENDENT DRUG IMMUNIZATION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-207-5751
Mailing Address - Street 1:28 KINGSTON RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-4814
Mailing Address - Country:US
Mailing Address - Phone:410-687-1115
Mailing Address - Fax:410-687-0032
Practice Address - Street 1:28 KINGSTON RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21220-4814
Practice Address - Country:US
Practice Address - Phone:410-687-1115
Practice Address - Fax:410-687-0032
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDEPENDENT DRUG
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP040093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404088100Medicaid
MD404088100Medicaid