Provider Demographics
NPI:1609358050
Name:CALLAHAN, FALLON
Entity Type:Individual
Prefix:
First Name:FALLON
Middle Name:
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 BEECH TREE RIDGE
Mailing Address - Street 2:
Mailing Address - City:KILLINGWORTH
Mailing Address - State:CT
Mailing Address - Zip Code:06419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:136 SAMSON ROCK DRIVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06413
Practice Address - Country:US
Practice Address - Phone:203-245-7467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-02
Last Update Date:2018-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0014578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist