Provider Demographics
NPI:1194760520
Name:THE PAVILION CORPORATION
Entity type:Organization
Organization Name:THE PAVILION CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:ADESOLA
Authorized Official - Middle Name:HAKEEM
Authorized Official - Last Name:OTUBANJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-467-4471
Mailing Address - Street 1:453 E 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-4426
Mailing Address - Country:US
Mailing Address - Phone:410-467-4471
Mailing Address - Fax:410-467-4553
Practice Address - Street 1:453 E 28TH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-4426
Practice Address - Country:US
Practice Address - Phone:410-467-4471
Practice Address - Fax:410-467-4553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
MDP022253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD014402900Medicaid
2122404OtherOTHER ID NUMBER
MD014402900Medicaid