Provider Demographics
NPI:1528426574
Name:NOWOBILSKI, CASEY (RPH)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:NOWOBILSKI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HUNTING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070
Mailing Address - Country:US
Mailing Address - Phone:860-253-2605
Mailing Address - Fax:860-749-7134
Practice Address - Street 1:153 HAZARD AVE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4592
Practice Address - Country:US
Practice Address - Phone:860-253-2605
Practice Address - Fax:860-749-7134
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT09123183500000X
IL051-036143183500000X
MAPH234374183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT09123OtherCT REG