Provider Demographics
NPI:1386363679
Name:MERCANTILE PHARMACY
Entity type:Organization
Organization Name:MERCANTILE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAPIAMBA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTEBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-404-6067
Mailing Address - Street 1:3939 S CAPITOL ST SW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-2308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 MERCANTILE LN STE 252
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5333
Practice Address - Country:US
Practice Address - Phone:301-404-6067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy