Provider Demographics
NPI:1487017067
Name:CONNECTICUT PHARMACY DIRECT LLC
Entity Type:Organization
Organization Name:CONNECTICUT PHARMACY DIRECT LLC
Other - Org Name:CONNECTICUT PHARMACY DIRECT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-518-1146
Mailing Address - Street 1:10 FAIRFIELD BLVD UNIT C
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-5903
Mailing Address - Country:US
Mailing Address - Phone:203-443-1213
Mailing Address - Fax:203-443-1085
Practice Address - Street 1:10 FAIRFIELD BLVD UNIT C
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-5903
Practice Address - Country:US
Practice Address - Phone:203-443-1213
Practice Address - Fax:203-443-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNR1506333600000X
NY0353943336C0003X
RIPHN112513336S0011X
CTPCY.00023313336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008066088Medicaid
2159143OtherPK