Provider Demographics
NPI:1598202822
Name:SMITH, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1914
Mailing Address - Country:US
Mailing Address - Phone:860-423-6304
Mailing Address - Fax:860-423-5873
Practice Address - Street 1:525 BUCKLAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3746
Practice Address - Country:US
Practice Address - Phone:860-644-4241
Practice Address - Fax:860-644-6883
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2022-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12693183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist