Provider Demographics
NPI:1487298782
Name:FREDERICK RAY PHARMACY LLC
Entity type:Organization
Organization Name:FREDERICK RAY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:TAVARES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:860-367-4773
Mailing Address - Street 1:12 KEYBOARD LN
Mailing Address - Street 2:
Mailing Address - City:IVORYTON
Mailing Address - State:CT
Mailing Address - Zip Code:06442-1265
Mailing Address - Country:US
Mailing Address - Phone:860-367-4773
Mailing Address - Fax:
Practice Address - Street 1:26 FALLS RD
Practice Address - Street 2:
Practice Address - City:MOODUS
Practice Address - State:CT
Practice Address - Zip Code:06469-1262
Practice Address - Country:US
Practice Address - Phone:860-367-4773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-30
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy