Healthcare Provider Details

I. General information

NPI: 1710428131
Provider Name (Legal Business Name): ICON HEALTH SCIENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 RICHARDS AVE 3RD FLOOR
NORWALK CT
06854-2319
US

IV. Provider business mailing address

40 RICHARDS AVE 3RD FLOOR
NORWALK CT
06854-2319
US

V. Phone/Fax

Practice location:
  • Phone: 800-243-8370
  • Fax: 888-374-0626
Mailing address:
  • Phone: 800-243-8370
  • Fax: 888-374-0626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberD0067749
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberD0067749
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License NumberD0067749
License Number StateMD

VIII. Authorized Official

Name: DR. IKECHUKWU (IKAY) KANAYO ENU
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 617-905-4430