Provider Demographics
NPI:1194888453
Name:MAIN ST CHEMISTS INC
Entity type:Organization
Organization Name:MAIN ST CHEMISTS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DAMARAJU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:203-755-7200
Mailing Address - Street 1:2152 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-2603
Mailing Address - Country:US
Mailing Address - Phone:203-755-7200
Mailing Address - Fax:203-755-7100
Practice Address - Street 1:2152 E MAIN ST
Practice Address - Street 2:EAST MAIN PHARMACY
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-2603
Practice Address - Country:US
Practice Address - Phone:203-755-7200
Practice Address - Fax:203-755-7100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004243664Medicaid
CT5242410001Medicare ID - Type Unspecified