Provider Demographics
NPI:1154378685
Name:SEQUON LLC
Entity type:Organization
Organization Name:SEQUON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:GANSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-394-5671
Mailing Address - Street 1:601 CHINQUAPIN ROUND RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-4009
Mailing Address - Country:US
Mailing Address - Phone:443-837-0200
Mailing Address - Fax:410-990-4455
Practice Address - Street 1:601 CHINQUAPIN ROUND RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-4009
Practice Address - Country:US
Practice Address - Phone:443-837-0200
Practice Address - Fax:410-990-4455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-29
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MDPW03033336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2037900OtherPK
MD002538100Medicaid
5470610002Medicare NSC