Provider Demographics
NPI:1346984838
Name:FAIR HAVEN COMMUNITY HEALTH CARE
Entity Type:Organization
Organization Name:FAIR HAVEN COMMUNITY HEALTH CARE
Other - Org Name:GRAND PHARMACY 111
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATRIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-777-7411
Mailing Address - Street 1:221 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-4022
Mailing Address - Country:US
Mailing Address - Phone:203-871-4188
Mailing Address - Fax:
Practice Address - Street 1:111 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3907
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-21
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy