Healthcare Provider Details

I. General information

NPI: 1164587580
Provider Name (Legal Business Name): BONNEVILLE RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 WESTCOTT RD
DANIELSON CT
06239-2929
US

IV. Provider business mailing address

77 WESTCOTT RD
DANIELSON CT
06239-2929
US

V. Phone/Fax

Practice location:
  • Phone: 860-774-9362
  • Fax: 860-779-2647
Mailing address:
  • Phone: 860-774-9362
  • Fax: 860-779-2647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPCY0000159
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2138266
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: RAVINDER ANNAMANENI
Title or Position: MEMBER
Credential:
Phone: 860-774-9362