Provider Demographics
NPI:1588761324
Name:CHESTERTOWN PHARMACY LLC
Entity type:Organization
Organization Name:CHESTERTOWN PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARM
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:TINELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-778-2575
Mailing Address - Street 1:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-0555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:329 HIGH ST
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-1333
Practice Address - Country:US
Practice Address - Phone:410-778-2575
Practice Address - Fax:410-778-7311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP055443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2107173OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MD033152000Medicaid
2107173OtherNCPDP PROVIDER IDENTIFICATION NUMBER