Provider Demographics
NPI:1962759316
Name:CIVIC HEALTH SERVICES 2 LLC
Entity type:Organization
Organization Name:CIVIC HEALTH SERVICES 2 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAHEED
Authorized Official - Middle Name:
Authorized Official - Last Name:AZIZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:410-749-5900
Mailing Address - Street 1:337 CIVIC AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5231
Mailing Address - Country:US
Mailing Address - Phone:410-749-5900
Mailing Address - Fax:410-749-5901
Practice Address - Street 1:613 W STEIN HWY
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-1203
Practice Address - Country:US
Practice Address - Phone:302-629-3737
Practice Address - Fax:302-629-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-04
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
DEA300009353336C0003X, 3336C0003X
MDP059703336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136526OtherPK
DE1962759316Medicaid