Provider Demographics
NPI:1306105127
Name:INDIAN HEAD PHARMACY INC
Entity type:Organization
Organization Name:INDIAN HEAD PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:301-743-3875
Mailing Address - Street 1:4115 INDIAN HEAD HWY
Mailing Address - Street 2:
Mailing Address - City:INDIAN HEAD
Mailing Address - State:MD
Mailing Address - Zip Code:20640-1750
Mailing Address - Country:US
Mailing Address - Phone:301-684-2580
Mailing Address - Fax:301-684-2593
Practice Address - Street 1:4115 INDIAN HEAD HWY
Practice Address - Street 2:
Practice Address - City:INDIAN HEAD
Practice Address - State:MD
Practice Address - Zip Code:20640-1750
Practice Address - Country:US
Practice Address - Phone:301-684-2580
Practice Address - Fax:301-684-2593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP057253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135309OtherPK
MD335427000Medicaid