Healthcare Provider Details

I. General information

NPI: 1306441225
Provider Name (Legal Business Name): MARY CORMIER RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MAIN ST
HEBRON CT
06248-1518
US

IV. Provider business mailing address

108 CHERRY SWAMP RD
MOODUS CT
06469-1039
US

V. Phone/Fax

Practice location:
  • Phone: 860-228-3888
  • Fax:
Mailing address:
  • Phone: 186-087-3998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8363
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: