Provider Demographics
NPI:1306117916
Name:POPLAR GROVE PHARMACY, INC
Entity type:Organization
Organization Name:POPLAR GROVE PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NWOGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-955-3081
Mailing Address - Street 1:14908 MEANDERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-2217
Mailing Address - Country:US
Mailing Address - Phone:240-646-4818
Mailing Address - Fax:410-945-5590
Practice Address - Street 1:709 POPLAR GROVE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-4625
Practice Address - Country:US
Practice Address - Phone:410-945-5555
Practice Address - Fax:410-945-5590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MDP056393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD115209200Medicaid
2134376OtherPK