Healthcare Provider Details

I. General information

NPI: 1609306919
Provider Name (Legal Business Name): CCR PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 MAIN AVE
WARWICK RI
02886-1940
US

IV. Provider business mailing address

1165 MAIN AVE
WARWICK RI
02886-1940
US

V. Phone/Fax

Practice location:
  • Phone: 401-861-1194
  • Fax: 401-383-7773
Mailing address:
  • Phone: 401-861-1194
  • Fax: 401-383-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPHA00542
License Number StateRI

VIII. Authorized Official

Name: PAUL CAPUANO
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 401-861-1194