Provider Demographics
NPI:1174509939
Name:GREENVILLE DRUG STORE INC
Entity Type:Organization
Organization Name:GREENVILLE DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KISZKIEL
Authorized Official - Suffix:II
Authorized Official - Credentials:RPH
Authorized Official - Phone:860-889-9857
Mailing Address - Street 1:213 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-3801
Mailing Address - Country:US
Mailing Address - Phone:860-889-9857
Mailing Address - Fax:860-886-0950
Practice Address - Street 1:213 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-3801
Practice Address - Country:US
Practice Address - Phone:860-889-9857
Practice Address - Fax:860-886-0950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT731183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0299200001Medicare ID - Type Unspecified