Provider Demographics
NPI:1235146804
Name:DURHAM PHARMCO INC
Entity Type:Organization
Organization Name:DURHAM PHARMCO INC
Other - Org Name:DURHAM HEALTHMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:860-349-3478
Mailing Address - Street 1:321 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06422-1614
Mailing Address - Country:US
Mailing Address - Phone:860-349-3478
Mailing Address - Fax:860-349-1240
Practice Address - Street 1:321 MAIN ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:CT
Practice Address - Zip Code:06422-1614
Practice Address - Country:US
Practice Address - Phone:860-349-3478
Practice Address - Fax:860-349-1240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CTPCY00001913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004093481Medicaid
1999590OtherPK
1999590OtherPK