Provider Demographics
NPI:1629665492
Name:TYRRELL, MARY ELSENBOSS (BS PHARM, PD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELSENBOSS
Last Name:TYRRELL
Suffix:
Gender:F
Credentials:BS PHARM, PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 363
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-0363
Mailing Address - Country:US
Mailing Address - Phone:203-263-2595
Mailing Address - Fax:203-263-7244
Practice Address - Street 1:2 MAIN ST N
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-2950
Practice Address - Country:US
Practice Address - Phone:203-263-2595
Practice Address - Fax:203-263-7244
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0005949183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist