Healthcare Provider Details

I. General information

NPI: 1396656013
Provider Name (Legal Business Name): ALEXA MYTKO PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2639 MAIN ST
GLASTONBURY CT
06033-2023
US

IV. Provider business mailing address

21 SUMMIT ST
MANCHESTER CT
06040-4216
US

V. Phone/Fax

Practice location:
  • Phone: 860-659-1329
  • Fax:
Mailing address:
  • Phone: 516-749-0668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPCT.0017462
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: