1992769350 NPI number — MEDICINE CENTRE HOPE STREET LLC

Table of content: (NPI 1992769350)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992769350 NPI number — MEDICINE CENTRE HOPE STREET LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICINE CENTRE HOPE STREET LLC
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:
CONNECTICUT PHARMACY MEDICAL SUPPLY
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:
1992769350
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:
10 FAIRFIELD BLVD
Provider Second Line Business Mailing Address:
UNIT C
Provider Business Mailing Address City Name:
WALLINGFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06492-5903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-939-1836
Provider Business Mailing Address Fax Number:
203-939-1837

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
664 MAIN AVE
Provider Second Line Business Practice Location Address:
UNIT B101
Provider Business Practice Location Address City Name:
NORWALK
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06851-1162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-939-1836
Provider Business Practice Location Address Fax Number:
203-939-1837
Provider Enumeration Date:
04/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOLAK
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
203-518-1147

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  28RO00114900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 033409 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: NP000838 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: PHN10764 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X , with the licence number: 0214001732 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X , with the licence number: PCY0000434 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336M0002X , with the licence number: 036.125415 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 004249901 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2002651 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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