Provider Demographics
NPI:1003968488
Name:SOUTHWOOD PHARMACY, INC
Entity Type:Organization
Organization Name:SOUTHWOOD PHARMACY, INC
Other - Org Name:SOUTHWOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SZEWCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:860-749-8334
Mailing Address - Street 1:89 RAFFIA RD
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-5157
Mailing Address - Country:US
Mailing Address - Phone:860-749-8334
Mailing Address - Fax:860-749-8156
Practice Address - Street 1:89 RAFFIA RD
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-5157
Practice Address - Country:US
Practice Address - Phone:860-749-8334
Practice Address - Fax:860-749-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0708353OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CT004028817Medicaid