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NPI Code Detail

MEDICARE: MAIN STREET PHARMACY 3 LLC

MEDICARE: MAIN STREET PHARMACY 3 LLC
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
1333600000XPharmacy
23336L0003XLong Term Care PharmacyPCY2190CT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12170877OTHERPK
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1780182766
Entity Type Code : Organization
Provider Name (Legal Business Name) : MAIN STREET PHARMACY 3 LLC
Provider Business Mailing Address
First Line : 2117 BOSTON AVE
Second Line :
City : BRIDGEPORT
State : CT
Zip : 06610-3030
Country : US
Telephone Number : 203-212-3800
Fax Number : 203-212-3802
Provider Business Practice Location Address
First Line : 2117 BOSTON AVE
Second Line :
City : BRIDGEPORT
State : CT
Zip : 06610-3030
Country : US
Telephone Number : 203-212-3800
Fax Number : 203-212-3802
Authorized Official
Title or Position : MEMBER
Name : JEAN JACOB
Credential :
Telephone Number : 203-212-3800
Provider Enumeration Date : 01/25/2018
Last Update Date : 01/25/2018

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Directions to “MAIN STREET PHARMACY 3 LLC ” Practice Location

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