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
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