MEDICARE: MR. IAN THOMAS MCCOLL PHARM. D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	0011990	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0011990	OTHER	CT	CT DEPARTMET OF CONSUMER PROTECTION

General Provider Information

NPI Number	:	1598292922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IAN THOMAS MCCOLL PHARM. D

Provider Business Mailing Address
First Line	:	150 S MAIN ST
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-3432
Country	:	US
Telephone Number	:	860-561-6164
Fax Number	:	860-561-8546

Provider Business Practice Location Address
First Line	:	150 S MAIN ST
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-3432
Country	:	US
Telephone Number	:	860-561-6164
Fax Number	:	860-561-8546

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2017
Last Update Date	:	07/21/2022

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