Provider Demographics
NPI:1104996099
Name:DECK LLC
Entity type:Organization
Organization Name:DECK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HOPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:410-745-6700
Mailing Address - Street 1:204 S TALBOT
Mailing Address - Street 2:PO BOX 567
Mailing Address - City:ST MICHAELS
Mailing Address - State:MD
Mailing Address - Zip Code:21663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 S TALBOT
Practice Address - Street 2:
Practice Address - City:ST MICHAELS
Practice Address - State:MD
Practice Address - Zip Code:21663
Practice Address - Country:US
Practice Address - Phone:410-745-6700
Practice Address - Fax:410-745-4016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP022803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406149700Medicaid
2122911OtherNCPDP PROVIDER IDENTIFICATION NUMBER
2122911OtherNCPDP PROVIDER IDENTIFICATION NUMBER