Provider Demographics
NPI:1194231571
Name:WOODMARK PHARMACY OF CT LLC
Entity Type:Organization
Organization Name:WOODMARK PHARMACY OF CT LLC
Other - Org Name:WOODMARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-817-5075
Mailing Address - Street 1:500 SENECA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14204-1963
Mailing Address - Country:US
Mailing Address - Phone:716-633-3900
Mailing Address - Fax:860-996-2086
Practice Address - Street 1:41 NORTHWEST DR
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-1234
Practice Address - Country:US
Practice Address - Phone:860-846-6369
Practice Address - Fax:860-996-2086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-20
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CTPCY23663336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176188OtherPK