Provider Demographics
NPI:1386893642
Name:EAST PINES PHARMACY LLC
Entity type:Organization
Organization Name:EAST PINES PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OMOTAYO
Authorized Official - Middle Name:
Authorized Official - Last Name:AWOTUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-459-6211
Mailing Address - Street 1:6003 66TH AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1780
Mailing Address - Country:US
Mailing Address - Phone:301-459-6211
Mailing Address - Fax:301-459-6217
Practice Address - Street 1:6003 66TH AVE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1780
Practice Address - Country:US
Practice Address - Phone:301-459-6211
Practice Address - Fax:301-459-6217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2013-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP048213336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD440047000Medicaid
2134245OtherNCPDP PROVIDER IDENTIFICATION NUMBER
2134245OtherNCPDP PROVIDER IDENTIFICATION NUMBER
6288560002Medicare NSC