Provider Demographics
NPI:1376904789
Name:EGAN, CHRISTINE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:EGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:BURBANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:103 CLIFFSIDE DR UNIT C
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3464
Mailing Address - Country:US
Mailing Address - Phone:860-798-0945
Mailing Address - Fax:
Practice Address - Street 1:3514 MAIN ST
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:CT
Practice Address - Zip Code:06238-1551
Practice Address - Country:US
Practice Address - Phone:860-742-3543
Practice Address - Fax:860-742-3548
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT 0010572183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist