Healthcare Provider Details

I. General information

NPI: 1609109842
Provider Name (Legal Business Name): MAIN STREET PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2009
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 MAIN ST # 1J
BRIDGEPORT CT
06604-4221
US

IV. Provider business mailing address

1005 MAIN ST # 1J
BRIDGEPORT CT
06604-4221
US

V. Phone/Fax

Practice location:
  • Phone: 203-870-9901
  • Fax: 203-870-9903
Mailing address:
  • Phone: 203-870-9901
  • Fax: 203-870-9903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPCY0002147
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. JEAN JACOB
Title or Position: OWNER
Credential:
Phone: 914-843-1881