Provider Demographics
NPI:1235236431
Name:ROBERT KEVORKIAN
Entity Type:Organization
Organization Name:ROBERT KEVORKIAN
Other - Org Name:SIMSBURY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KEVORKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH PHD
Authorized Official - Phone:860-658-4489
Mailing Address - Street 1:1418 HOPMEADOW ST
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-1410
Mailing Address - Country:US
Mailing Address - Phone:860-658-4489
Mailing Address - Fax:860-651-7663
Practice Address - Street 1:1418 HOPMEADOW ST
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-1410
Practice Address - Country:US
Practice Address - Phone:860-658-4489
Practice Address - Fax:860-651-7663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CTPCY00008563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004030763Medicaid
1998104OtherPK