Provider Demographics
NPI:1689676074
Name:JEWETT CITY PHARMACY
Entity Type:Organization
Organization Name:JEWETT CITY PHARMACY
Other - Org Name:JEWETT CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMARI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:860-376-4468
Mailing Address - Street 1:78 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JEWETT CITY
Mailing Address - State:CT
Mailing Address - Zip Code:06351-2226
Mailing Address - Country:US
Mailing Address - Phone:860-376-4468
Mailing Address - Fax:860-376-0399
Practice Address - Street 1:78 MAIN ST
Practice Address - Street 2:
Practice Address - City:JEWETT CITY
Practice Address - State:CT
Practice Address - Zip Code:06351-2226
Practice Address - Country:US
Practice Address - Phone:860-376-4468
Practice Address - Fax:860-376-0399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
CTPCY.00006573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004167963Medicaid
CT004032751Medicaid
CT004167971Medicaid
2001749OtherPK