Provider Demographics
NPI:1013190776
Name:PHARMACITY LLC
Entity Type:Organization
Organization Name:PHARMACITY LLC
Other - Org Name:STORRS DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAUFEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAJUDEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-766-1151
Mailing Address - Street 1:1232 STORRS RD
Mailing Address - Street 2:STE 6
Mailing Address - City:STORRS MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06268-2232
Mailing Address - Country:US
Mailing Address - Phone:860-429-9365
Mailing Address - Fax:860-429-0043
Practice Address - Street 1:1232 STORRS RD
Practice Address - Street 2:STE 6
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06268-2232
Practice Address - Country:US
Practice Address - Phone:860-429-9365
Practice Address - Fax:860-429-0043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCY00006453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0720979OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CT500000216Medicaid
6095740001Medicare NSC