=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437233566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EZ PHARM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 166 WATERBURY RD
-----------------------------------------------------
City | PROSPECT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06712-1200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-284-0020
-----------------------------------------------------
Fax | 860-201-1200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 406
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06001-0406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXEC OFFICER
-----------------------------------------------------
Name | JOHN KUZIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-284-0020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PCY2052
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------