Provider Demographics
NPI:1366678658
Name:MRAZIK, ERNEST JR
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:MRAZIK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 PARKER ST
Mailing Address - Street 2:APT. C306
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-5834
Mailing Address - Country:US
Mailing Address - Phone:203-269-0578
Mailing Address - Fax:
Practice Address - Street 1:50 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5654
Practice Address - Country:US
Practice Address - Phone:203-688-7064
Practice Address - Fax:203-688-9606
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4458183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist