Provider Demographics
NPI:1154986867
Name:BUNKER HILL PHARMACY
Entity type:Organization
Organization Name:BUNKER HILL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:203-574-7825
Mailing Address - Street 1:256 BUNKER HILL AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708
Mailing Address - Country:US
Mailing Address - Phone:203-574-7825
Mailing Address - Fax:203-574-4972
Practice Address - Street 1:256 BUNKER HILL AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:203-574-7825
Practice Address - Fax:203-574-4972
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BUNKER HILL PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004016036OtherMEDICAID DMC
CT004027306Medicaid