Healthcare Provider Details

I. General information

NPI: 1134184260
Provider Name (Legal Business Name): MARY E TYRRELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MAIN ST N
WOODBURY CT
06798-2950
US

IV. Provider business mailing address

2 MAIN ST N P.O. BOX 363
WOODBURY CT
06798-2950
US

V. Phone/Fax

Practice location:
  • Phone: 203-263-2018
  • Fax: 203-263-7244
Mailing address:
  • Phone: 203-263-2018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number51
License Number StateCT

VIII. Authorized Official

Name: MRS. MARY E TYRRELL
Title or Position: SOLE PROPRIETOR
Credential:
Phone: 203-263-2018