Provider Demographics
NPI:1316249352
Name:MAIN STREET PHARMACY 3 LLC
Entity type:Organization
Organization Name:MAIN STREET PHARMACY 3 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:2032-123-8001
Mailing Address - Street 1:2117 BOSTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-3030
Mailing Address - Country:US
Mailing Address - Phone:203-212-3800
Mailing Address - Fax:203-212-3802
Practice Address - Street 1:2117 BOSTON AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-3030
Practice Address - Country:US
Practice Address - Phone:203-212-3800
Practice Address - Fax:203-212-3802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-24
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336C0004X, 3336S0011X
CT332BP3500X
CTPCY2190333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008032995Medicaid
CTD300189345Medicare PIN
CT008032995Medicaid