1932203510 NPI number — LUPES DRUG STORE INC

Table of content: (NPI 1932203510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932203510 NPI number — LUPES DRUG STORE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUPES DRUG STORE 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:
LUPES DRUG STORE OF FAIRFIELD
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:
1932203510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2035 BLACK ROCK TPKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06825-3550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-368-1955
Provider Business Mailing Address Fax Number:
203-384-2551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2035 BLACK ROCK TPKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06825-3550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-368-1955
Provider Business Practice Location Address Fax Number:
203-384-2551
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MASSARO
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
203-368-1955

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PCY.0000860 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1998247 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 004030771 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004017943 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com