Provider Demographics
NPI:1396879862
Name:FAIRLAND MARKET INC.
Entity type:Organization
Organization Name:FAIRLAND MARKET INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CHERRY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-373-5848
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-0098
Mailing Address - Country:US
Mailing Address - Phone:301-373-5848
Mailing Address - Fax:301-373-5338
Practice Address - Street 1:40845 MERCHANTS LN
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-3767
Practice Address - Country:US
Practice Address - Phone:301-997-1849
Practice Address - Fax:301-997-1284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP017553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4017153Medicaid
MD2118897OtherNCPDP
MDP01755OtherMD PHARMACY PERMIT