Healthcare Provider Details

I. General information

NPI: 1568965796
Provider Name (Legal Business Name): ENFIELD COMPOUNDING PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 HAZARD AVE BLDG 4
ENFIELD CT
06082-4585
US

IV. Provider business mailing address

PO BOX 1152
ENFIELD CT
06083-1152
US

V. Phone/Fax

Practice location:
  • Phone: 860-749-1101
  • Fax: 860-749-1106
Mailing address:
  • Phone: 860-749-1101
  • Fax: 860-749-1106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number2362
License Number StateCT

VIII. Authorized Official

Name: FRANK PAGE
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 860-749-1101