Provider Demographics
NPI:1598777153
Name:DRUG SHOPPE HEALTH SOLUTIONS OF CONNECTICUT, INC
Entity Type:Organization
Organization Name:DRUG SHOPPE HEALTH SOLUTIONS OF CONNECTICUT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:ETUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-749-3824
Mailing Address - Street 1:155 HAZARD AVE UNIT 16
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4580
Mailing Address - Country:US
Mailing Address - Phone:860-749-3824
Mailing Address - Fax:
Practice Address - Street 1:155 HAZARD AVE UNIT 16
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4580
Practice Address - Country:US
Practice Address - Phone:860-749-3824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
183500000X
CT2068332B00000X, 3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004262820Medicaid
CT004262838Medicaid
CT5860090001Medicare NSC