Provider Demographics
NPI:1154354405
Name:GIANT OF MARYLAND LLC
Entity type:Organization
Organization Name:GIANT OF MARYLAND LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:DAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-770-8782
Mailing Address - Street 1:46 BUREAU DR
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-1402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46 BUREAU DR
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-1402
Practice Address - Country:US
Practice Address - Phone:301-840-0815
Practice Address - Fax:301-590-0845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPO0284332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD690006200Medicaid
2110245OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2110245OtherOTHER ID NUMBER-COMMERCIAL NUMBER