Healthcare Provider Details

I. General information

NPI: 1134765258
Provider Name (Legal Business Name): IVAN JOHN PHILIPOSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2019
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 CAMPBELL AVE
WEST HAVEN CT
06516-2770
US

IV. Provider business mailing address

910 SUMMER ST
STAMFORD CT
06905-5502
US

V. Phone/Fax

Practice location:
  • Phone: 203-932-5711
  • Fax:
Mailing address:
  • Phone: 516-902-6492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPCT.0014251
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: