Provider Demographics
NPI:1619378890
Name:PHARMACY & PHARMACEUTICAL SERVICES PROVIDER
Entity type:Organization
Organization Name:PHARMACY & PHARMACEUTICAL SERVICES PROVIDER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT,CEO & OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:F
Authorized Official - Last Name:ETEBOM
Authorized Official - Suffix:
Authorized Official - Credentials:BS BSPHARM
Authorized Official - Phone:301-352-2514
Mailing Address - Street 1:13202 STEEPLECHASE DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4542
Mailing Address - Country:US
Mailing Address - Phone:301-352-2514
Mailing Address - Fax:301-805-0664
Practice Address - Street 1:13202 STEEPLECHASE DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4542
Practice Address - Country:US
Practice Address - Phone:301-352-2514
Practice Address - Fax:301-805-0664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13780171W00000X, 174400000X, 1744R1102X, 174H00000X, 183500000X, 1835G0303X, 1835N1003X, 1835P1200X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty
No171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No1744R1102XOther Service ProvidersSpecialistResearch StudyGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No1835G0303XPharmacy Service ProvidersPharmacistGeriatricGroup - Multi-Specialty
No1835N1003XPharmacy Service ProvidersPharmacistNutrition SupportGroup - Multi-Specialty
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
URLOtherWWW.PHARMACYPHARMACEUTICALSERVICES.COM