MEDICARE: COMPUTERX PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	1524	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174505036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPUTERX PHARMACY INC

Provider Business Mailing Address
First Line	:	35 ONTARIO ST
Second Line	:
City	:	STRATFORD
State	:	CT
Zip	:	06615-7135
Country	:	US
Telephone Number	:	203-375-8000
Fax Number	:	800-784-5430

Provider Business Practice Location Address
First Line	:	35 ONTARIO ST
Second Line	:
City	:	STRATFORD
State	:	CT
Zip	:	06615-7135
Country	:	US
Telephone Number	:	203-375-8000
Fax Number	:	800-784-5430

Authorized Official
Title or Position	:	CHEIF EXECUTIVE OFFICER
Name	:	DR. MICHAEL WILLIAM LICAMELE
Credential	:	PHARM. D.
Telephone Number	:	203-375-8000

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	08/22/2020

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