Healthcare Provider Details

I. General information

NPI: 1073130787
Provider Name (Legal Business Name): WASSEF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 BOSTON POST RD
OLD SAYBROOK CT
06475-1506
US

IV. Provider business mailing address

535 BOSTON POST RD
OLD SAYBROOK CT
06475-1506
US

V. Phone/Fax

Practice location:
  • Phone: 860-339-5667
  • Fax: 860-339-5796
Mailing address:
  • Phone: 860-339-5667
  • Fax: 860-339-5796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00806330
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name: NAGY WASSEF
Title or Position: MEMBER
Credential:
Phone: 860-339-5667