Organization
MT VERNON PHARMACY AT FALLSWAY INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
STEPHEN WIENNER (PRESIDENT)
(410) 962-1100
Entity
Organization
Contact information
Practice address
421 FALLSWAY, BALTIMORE, MD 21202-4800
(410) 962-1100
Mailing address
900 CATHEDRAL ST, BALTIMORE, MD 21201-5311
(410) 539-8030
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
P05345
MD
3336S0011X
Specialty Pharmacy
P05345
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036258100
—
MD
05
—
036800800
—
MD
01
—
208979
MEDICARE MASS IMMUNIZER PTAN
MD
Enumeration date
09/18/2014
Last updated
09/18/2014
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