Provider Demographics
NPI:1093340820
Name:FREDERICK RAY PHARMACY LLC
Entity Type:Organization
Organization Name:FREDERICK RAY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVARES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:860-367-4773
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:MOODUS
Mailing Address - State:CT
Mailing Address - Zip Code:06469-0457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26 FALLS RD
Practice Address - Street 2:
Practice Address - City:MOODUS
Practice Address - State:CT
Practice Address - Zip Code:06469-1262
Practice Address - Country:US
Practice Address - Phone:860-367-4773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy