Provider Demographics
NPI:1598828873
Name:HEALTH COMPLEX MEDICAL, LLC
Entity type:Organization
Organization Name:HEALTH COMPLEX MEDICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSALESI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-246-9499
Mailing Address - Street 1:84 PROGRESS LN
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-3829
Mailing Address - Country:US
Mailing Address - Phone:203-753-7778
Mailing Address - Fax:203-346-7593
Practice Address - Street 1:84 PROGRESS LN
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-3829
Practice Address - Country:US
Practice Address - Phone:203-753-7778
Practice Address - Fax:203-346-7593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6569183500000X
3336M0002X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1846OtherCT PHARMACY LICENSE
CT004244381Medicaid
0719863OtherNCPDP
0719863OtherNCPDP