Provider Demographics
NPI:1619228202
Name:SALEM PHARMACY LLC
Entity Type:Organization
Organization Name:SALEM PHARMACY LLC
Other - Org Name:SALEM HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKOLINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-655-2885
Mailing Address - Street 1:20 HARTFORD RD STE 16
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:CT
Mailing Address - Zip Code:06420-3800
Mailing Address - Country:US
Mailing Address - Phone:860-949-8624
Mailing Address - Fax:860-949-8646
Practice Address - Street 1:20 HARTFORD RD STE 16
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:CT
Practice Address - Zip Code:06420-3800
Practice Address - Country:US
Practice Address - Phone:860-949-8624
Practice Address - Fax:860-949-8646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-24
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
CTPCY00022523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008042535Medicaid
0722923OtherNCPDP PROVIDER IDENTIFICATION NUMBER
6792920001Medicare NSC