Healthcare Provider Details

I. General information

NPI: 1174505036
Provider Name (Legal Business Name): COMPUTERX PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 ONTARIO ST
STRATFORD CT
06615-7135
US

IV. Provider business mailing address

35 ONTARIO ST
STRATFORD CT
06615-7135
US

V. Phone/Fax

Practice location:
  • Phone: 203-375-8000
  • Fax: 800-784-5430
Mailing address:
  • Phone: 203-375-8000
  • Fax: 800-784-5430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1524
License Number StateCT

VIII. Authorized Official

Name: DR. MICHAEL WILLIAM LICAMELE
Title or Position: CHEIF EXECUTIVE OFFICER
Credential: PHARM. D.
Phone: 203-375-8000