Provider Demographics
NPI:1659677185
Name:MEDSTAT PHARMACY LLC
Entity Type:Organization
Organization Name:MEDSTAT PHARMACY LLC
Other - Org Name:MEDSTAT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:PELC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-374-9210
Mailing Address - Street 1:41 NORTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-1234
Mailing Address - Country:US
Mailing Address - Phone:860-677-2934
Mailing Address - Fax:
Practice Address - Street 1:41 NORTHWEST DR
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-1234
Practice Address - Country:US
Practice Address - Phone:860-677-2934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-01
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CT00022073336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0722341OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CT6635230001Medicare NSC