Provider Demographics
NPI:1053410431
Name:MEDACCESS PHARMACY SVC LLC
Entity type:Organization
Organization Name:MEDACCESS PHARMACY SVC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:EJIKE
Authorized Official - Middle Name:I
Authorized Official - Last Name:UNEGBU
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:301-604-8500
Mailing Address - Street 1:7350 VAN DUSEN RD STE 120
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5267
Mailing Address - Country:US
Mailing Address - Phone:301-604-8500
Mailing Address - Fax:
Practice Address - Street 1:7350 VAN DUSEN RD STE 120
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5267
Practice Address - Country:US
Practice Address - Phone:301-604-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPO4144333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407083600Medicaid
MD5336150001Medicare NSC