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General NPI Number Information
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NPI Number | 1740658889
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Entity Type | Organization
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Legal Business Name | EVINE LLC
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Dates
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Enumeration Date | 09/07/2015
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Last Update Date | 09/07/2015
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Provider Practice Location Address
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Address Line | 54 TUTTLE PL
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City | MIDDLETOWN
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State | CT
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Zip | 06457-1863
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Country | US
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Telephone | 860-614-9000
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Fax |
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Provider Business Mailing Address
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Address Line | 54 TUTTLE PL
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City | MIDDLETOWN
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State | CT
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Zip | 06457-1863
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | LAWRENCE KOSOSKI
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Credential | R.PH
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Telephone | 413-636-5119
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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