Healthcare Provider Details

I. General information

NPI: 1366678658
Provider Name (Legal Business Name): ERNEST MRAZIK JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 06/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 YORK ST
NEW HAVEN CT
06511-5654
US

IV. Provider business mailing address

53 PARKER ST APT. C306
WALLINGFORD CT
06492-5834
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-7064
  • Fax: 203-688-9606
Mailing address:
  • Phone: 203-269-0578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4458
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: