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General NPI Number Information
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NPI Number | 1306601166
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Entity Type | Organization
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Legal Business Name | FAIR HAVEN PHARMACY LLC
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Dates
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Enumeration Date | 02/20/2024
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Last Update Date | 02/20/2024
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Provider Practice Location Address
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Address Line | 351 GRAND AVE
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City | NEW HAVEN
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State | CT
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Zip | 06513-3732
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Country | US
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Telephone | 203-923-3229
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Fax |
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Provider Business Mailing Address
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Address Line | 72 GRAND AVE
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City | NEW HAVEN
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State | CT
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Zip | 06513-3997
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Country | US
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Telephone | 203-923-3229
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | MANTHENA VARMA
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Credential |
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Telephone | 203-923-3229
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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