Provider Demographics
NPI:1609095868
Name:DANIELSON PHARMACY INC
Entity Type:Organization
Organization Name:DANIELSON PHARMACY INC
Other - Org Name:BONNEVILLE LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:NETHERCOTE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:508-450-3161
Mailing Address - Street 1:77 A WESTCOTT RD
Mailing Address - Street 2:
Mailing Address - City:DANIELSON
Mailing Address - State:CT
Mailing Address - Zip Code:06239
Mailing Address - Country:US
Mailing Address - Phone:860-774-6418
Mailing Address - Fax:860-779-2647
Practice Address - Street 1:77 A WESTCOTT RD
Practice Address - Street 2:
Practice Address - City:DANIELSON
Practice Address - State:CT
Practice Address - Zip Code:06239
Practice Address - Country:US
Practice Address - Phone:860-774-6418
Practice Address - Fax:860-779-2647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT20853336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0720739OtherNCPDP PROVIDER IDENTIFICATION NUMBER