Provider Demographics
NPI:1619212362
Name:PINK MERMAID LLC
Entity Type:Organization
Organization Name:PINK MERMAID LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASTECTOMY FITTER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RYALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-865-0825
Mailing Address - Street 1:1313 GOLD STAR HWY
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-2717
Mailing Address - Country:US
Mailing Address - Phone:860-865-0825
Mailing Address - Fax:860-865-0826
Practice Address - Street 1:1313 GOLD STAR HWY
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-2717
Practice Address - Country:US
Practice Address - Phone:860-865-0825
Practice Address - Fax:860-865-0826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies