Provider Demographics
NPI:1194752667
Name:EMPIRE PROFESSIONAL PHARMACY INC
Entity type:Organization
Organization Name:EMPIRE PROFESSIONAL PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNDIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-787-0030
Mailing Address - Street 1:200 HOSPITAL DR
Mailing Address - Street 2:STE 107
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5884
Mailing Address - Country:US
Mailing Address - Phone:410-787-0030
Mailing Address - Fax:410-787-0033
Practice Address - Street 1:200 HOSPITAL DR
Practice Address - Street 2:STE 107
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5884
Practice Address - Country:US
Practice Address - Phone:410-787-0030
Practice Address - Fax:410-787-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP00948333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD256723000Medicaid
2112009OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MD419578700Medicaid
MD419578700Medicaid