Provider Demographics
NPI:1568839876
Name:MY FAIR HAVEN PHARMACY LLC
Entity Type:Organization
Organization Name:MY FAIR HAVEN PHARMACY LLC
Other - Org Name:FAIR HAVEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MANTHENA
Authorized Official - Middle Name:V
Authorized Official - Last Name:VARMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-498-3479
Mailing Address - Street 1:72 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513
Mailing Address - Country:US
Mailing Address - Phone:203-498-3479
Mailing Address - Fax:203-498-8000
Practice Address - Street 1:72 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513
Practice Address - Country:US
Practice Address - Phone:203-498-3479
Practice Address - Fax:203-498-8000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CTPCY.00023153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008061384Medicaid
CT008064135OtherMEDICAID DME
CT008064135OtherMEDICAID DME