=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982281580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW ARELLANO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2021
-----------------------------------------------------
Last Update Date | 03/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 891 N COLONY RD
-----------------------------------------------------
City | WALLINGFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06492-2437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-294-8890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 GRANDVIEW AVE
-----------------------------------------------------
City | WALLINGFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06492-5109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PCT.0015315
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------