1386946366 NPI number — KILLINGWORTH FAMILY PHARMACY INC

Table of content: (NPI 1386946366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386946366 NPI number — KILLINGWORTH FAMILY PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KILLINGWORTH FAMILY PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KILLINGWORTH FAMILY PHARMACY INC.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386946366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
183 ROUTE 81 STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KILLINGWORTH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06419-1480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-452-4275
Provider Business Mailing Address Fax Number:
860-452-4278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
183 ROUTE 81 STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KILLINGWORTH
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06419-1480
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-452-4275
Provider Business Practice Location Address Fax Number:
860-452-4278
Provider Enumeration Date:
11/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LYKE
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER / PHCY MGR
Authorized Official Telephone Number:
860-452-4275

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PCY.0002196 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 008025521 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2127689 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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