Provider Demographics
NPI:1992763882
Name:SEYBRIDGE PHARMACY INC
Entity type:Organization
Organization Name:SEYBRIDGE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-888-0073
Mailing Address - Street 1:37 NEW HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-3460
Mailing Address - Country:US
Mailing Address - Phone:203-888-0073
Mailing Address - Fax:203-888-2932
Practice Address - Street 1:37 NEW HAVEN RD
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:CT
Practice Address - Zip Code:06483-3460
Practice Address - Country:US
Practice Address - Phone:203-888-0073
Practice Address - Fax:203-888-2932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CTPCY.00012923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004069175Medicaid
CT004069167Medicaid
0712162OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CT004069175Medicaid