Provider Demographics
NPI:1104915321
Name:ANTIETAM HEALTH SERVICES
Entity type:Organization
Organization Name:ANTIETAM HEALTH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:301-223-4100
Mailing Address - Street 1:307 E POTOMAC ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:MD
Mailing Address - Zip Code:21795-1203
Mailing Address - Country:US
Mailing Address - Phone:301-223-4100
Mailing Address - Fax:301-223-6133
Practice Address - Street 1:307 E POTOMAC STREET
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:MD
Practice Address - Zip Code:21795-1203
Practice Address - Country:US
Practice Address - Phone:301-223-4100
Practice Address - Fax:301-223-6133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP022953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy