Healthcare Provider Details

I. General information

NPI: 1063069334
Provider Name (Legal Business Name): TARA LYN KOWALSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 LINWOOD AVE
COLCHESTER CT
06415-1159
US

IV. Provider business mailing address

20 SETTLERS LN
COLCHESTER CT
06415-1774
US

V. Phone/Fax

Practice location:
  • Phone: 860-537-2570
  • Fax:
Mailing address:
  • Phone: 860-608-5527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPCT.0014905
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: