Provider Demographics
NPI:1003395542
Name:COUILLARD, MARYJANE (RPH)
Entity Type:Individual
Prefix:
First Name:MARYJANE
Middle Name:
Last Name:COUILLARD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 WATERFORD PKWY N
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1208
Mailing Address - Country:US
Mailing Address - Phone:860-447-3747
Mailing Address - Fax:
Practice Address - Street 1:155 WATERFORD PKWY N
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1208
Practice Address - Country:US
Practice Address - Phone:860-447-3747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4073183500000X
CTPCT.0014296183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist