Healthcare Provider Details

I. General information

NPI: 1205429362
Provider Name (Legal Business Name): HABIB THIAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HALLS RD
OLD LYME CT
06371
US

IV. Provider business mailing address

90 HALLS RD
OLD LYME CT
06371
US

V. Phone/Fax

Practice location:
  • Phone: 860-434-8111
  • Fax:
Mailing address:
  • Phone: 860-434-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPCT.0015506
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: