1174505036 NPI number — COMPUTERX PHARMACY INC

Table of content: (NPI 1174505036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174505036 NPI number — COMPUTERX PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPUTERX 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:
COMPUTERX PHARMACY IV
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:
1174505036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 ONTARIO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STRATFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06615-7135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-375-8000
Provider Business Mailing Address Fax Number:
800-784-5430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 ONTARIO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STRATFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06615-7135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-375-8000
Provider Business Practice Location Address Fax Number:
800-784-5430
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LICAMELE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
CHEIF EXECUTIVE OFFICER
Authorized Official Telephone Number:
203-375-8000

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1524 , 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: 4645110 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9003226900 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7419015 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02620148 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 852021 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9126431 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: XDME03019 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7419007 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81195000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0076567170003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0076567170002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2332587 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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