Provider Demographics
NPI:1063624922
Name:DANIELSON PHARMACY INC
Entity type:Organization
Organization Name:DANIELSON PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:F
Authorized Official - Last Name:NETHERCOTE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:860-774-9362
Mailing Address - Street 1:77 WESTCOTT RD
Mailing Address - Street 2:
Mailing Address - City:DANIELSON
Mailing Address - State:CT
Mailing Address - Zip Code:06239-2929
Mailing Address - Country:US
Mailing Address - Phone:860-774-9362
Mailing Address - Fax:860-779-2647
Practice Address - Street 1:77 WESTCOTT RD
Practice Address - Street 2:
Practice Address - City:DANIELSON
Practice Address - State:CT
Practice Address - Zip Code:06239-2929
Practice Address - Country:US
Practice Address - Phone:860-774-9362
Practice Address - Fax:860-779-2647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT159332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12DME0671CT01OtherBCBS
CT0777100001Medicare ID - Type Unspecified