Provider Demographics
NPI:1376209064
Name:FEDOR, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:FEDOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 AQUA VITAE RD
Mailing Address - Street 2:
Mailing Address - City:HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01035-9508
Mailing Address - Country:US
Mailing Address - Phone:413-923-4491
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT15660183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist