Provider Demographics
NPI:1457678468
Name:HANCOCK PHARMACY V LLC
Entity Type:Organization
Organization Name:HANCOCK PHARMACY V LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER / SP
Authorized Official - Prefix:MR
Authorized Official - First Name:SUDHEER
Authorized Official - Middle Name:
Authorized Official - Last Name:GHANTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-346-9700
Mailing Address - Street 1:644 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2731
Mailing Address - Country:US
Mailing Address - Phone:860-346-9700
Mailing Address - Fax:860-346-9702
Practice Address - Street 1:644 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-2731
Practice Address - Country:US
Practice Address - Phone:860-346-9700
Practice Address - Fax:860-346-9702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCY0002177332B00000X
CTPCY.00021773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT6481290001Medicare NSC