Provider Demographics
NPI:1992769350
Name:MEDICINE CENTRE HOPE STREET LLC
Entity type:Organization
Organization Name:MEDICINE CENTRE HOPE STREET LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-518-1147
Mailing Address - Street 1:10 FAIRFIELD BLVD
Mailing Address - Street 2:UNIT C
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-5903
Mailing Address - Country:US
Mailing Address - Phone:203-939-1836
Mailing Address - Fax:203-939-1837
Practice Address - Street 1:664 MAIN AVE
Practice Address - Street 2:UNIT B101
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-1162
Practice Address - Country:US
Practice Address - Phone:203-939-1836
Practice Address - Fax:203-939-1837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RO00114900332B00000X
NY033409333600000X
PANP0008383336C0003X
RIPHN107643336L0003X
VA02140017323336M0002X
CTPCY00004343336M0002X
VT036.1254153336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004249901Medicaid
2002651OtherPK
5458340001Medicare NSC