Provider Demographics
NPI:1992117279
Name:HALETHORPE DRUG IMMUNIZATION LLC
Entity type:Organization
Organization Name:HALETHORPE DRUG IMMUNIZATION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:V.P.
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARMER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:410-207-5751
Mailing Address - Street 1:1307 FRANCIS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-3913
Mailing Address - Country:US
Mailing Address - Phone:410-247-3344
Mailing Address - Fax:410-247-9110
Practice Address - Street 1:1307 FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21227-3913
Practice Address - Country:US
Practice Address - Phone:410-247-3344
Practice Address - Fax:410-247-9110
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERGOLD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP02423333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD241004400Medicaid
MD5140800001Medicare UPIN