Provider Demographics
NPI:1255316139
Name:COLONIAL DRUGGISTS OF WESTPORT INC
Entity Type:Organization
Organization Name:COLONIAL DRUGGISTS OF WESTPORT INC
Other - Org Name:COLONIAL DRUGGISTS INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REG PHAR AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:REG PHAR
Authorized Official - Phone:203-227-9538
Mailing Address - Street 1:611 POST RD E
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4548
Mailing Address - Country:US
Mailing Address - Phone:203-227-9538
Mailing Address - Fax:203-227-6581
Practice Address - Street 1:611 POST RD E
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4548
Practice Address - Country:US
Practice Address - Phone:203-227-9538
Practice Address - Fax:203-227-6581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CTPCY8643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT04030805Medicaid
1998904OtherPK
CT04030805Medicaid