Provider Demographics
NPI:1598213472
Name:MAIN STREET RX INC
Entity Type:Organization
Organization Name:MAIN STREET RX INC
Other - Org Name:MAIN STREET RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:DELILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:475-323-2100
Mailing Address - Street 1:266 S MAIN ST
Mailing Address - Street 2:SUITE D-2
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-6706
Mailing Address - Country:US
Mailing Address - Phone:475-323-2100
Mailing Address - Fax:
Practice Address - Street 1:266 S MAIN ST STE D-2
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-6706
Practice Address - Country:US
Practice Address - Phone:475-323-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336M0002X
FLPH295423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164148OtherPK