Healthcare Provider Details

I. General information

NPI: 1518493790
Provider Name (Legal Business Name): ANDREA IDUSUYI PHARM.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2017
Last Update Date: 05/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 BROAD ST
MANCHESTER CT
06040-4049
US

IV. Provider business mailing address

20 FRONT ST
HARTFORD CT
06103-2845
US

V. Phone/Fax

Practice location:
  • Phone: 860-647-0325
  • Fax:
Mailing address:
  • Phone: 781-244-3989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0013351
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: