Provider Demographics
NPI:1679614523
Name:CHIMYKE CORP
Entity type:Organization
Organization Name:CHIMYKE CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,RPH,AO
Authorized Official - Prefix:
Authorized Official - First Name:MERYLN
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:301-445-6050
Mailing Address - Street 1:7676 NEW HAMPSHIRE AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-7512
Mailing Address - Country:US
Mailing Address - Phone:301-445-6050
Mailing Address - Fax:301-445-6056
Practice Address - Street 1:7676 NEW HAMPSHIRE AVE
Practice Address - Street 2:STE 104
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-7512
Practice Address - Country:US
Practice Address - Phone:301-445-6050
Practice Address - Fax:301-445-6056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
MDP023003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD446889900Medicaid
2036501OtherPK
4319670001Medicare NSC