Healthcare Provider Details

I. General information

NPI: 1053772657
Provider Name (Legal Business Name): CAROL LEA OURS RPH, AEC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ANNIE GEORGE DR
MASHANTUCKET CT
06338-3801
US

IV. Provider business mailing address

1 ANNIE GEORGE DR
MASHANTUCKET CT
06338-3801
US

V. Phone/Fax

Practice location:
  • Phone: 888-779-6362
  • Fax: 800-779-6329
Mailing address:
  • Phone: 888-779-6362
  • Fax: 800-779-6329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8112
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3684
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: