Healthcare Provider Details

I. General information

NPI: 1447567961
Provider Name (Legal Business Name): HIGGANUM PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 KILLINGWORTH RD
HIGGANUM CT
06441-4242
US

IV. Provider business mailing address

PO BOX 540
HIGGANUM CT
06441-0540
US

V. Phone/Fax

Practice location:
  • Phone: 860-345-3607
  • Fax: 860-345-3611
Mailing address:
  • Phone: 860-345-3607
  • Fax: 860-345-3611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPCY.0002191
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GREGORY MCKENNA
Title or Position: MANAGING MEMBER
Credential:
Phone: 860-345-3607