Organization
THE PAVILION CORPORATION
Active
Organization
THE PAVILION CORPORATION
Active
Other names
WAVERLY PROFESSIONAL PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
ADESOLA HAKEEM OTUBANJO (PIC)
(410) 467-4471
Entity
Organization
Contact information
Practice address
453 E 28TH ST, BALTIMORE, MD 21218-4426
(410) 467-4471
(410) 467-4553
Mailing address
453 E 28TH ST, BALTIMORE, MD 21218-4426
(410) 467-4471
(410) 467-4553
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
P02225
MD
3336C0004X
Compounding Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
014402900
—
MD
01
—
2122404
OTHER ID NUMBER
—
Enumeration date
06/19/2006
Last updated
03/11/2010
Update your record
If you believe information in your NPPES record is inaccurate, or if you wish to update or deactivate your NPI, you can do so directly with CMS at https://nppes.cms.hhs.gov.
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