Provider Demographics
NPI:1386141463
Name:DANBURY PHARMACY LLC
Entity type:Organization
Organization Name:DANBURY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SOHAIB
Authorized Official - Middle Name:
Authorized Official - Last Name:KKALID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-629-0847
Mailing Address - Street 1:47 VILLAGE LN
Mailing Address - Street 2:APT 801
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1084
Mailing Address - Country:US
Mailing Address - Phone:219-629-0847
Mailing Address - Fax:
Practice Address - Street 1:35 WHITE ST UNIT 5
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6678
Practice Address - Country:US
Practice Address - Phone:203-679-9999
Practice Address - Fax:203-679-9000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-06
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CTPCY.00023713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176958OtherPK
CT008079206Medicaid