Provider Demographics
NPI:1689989782
Name:MAIN STREET PHARMACY 4 LLC
Entity Type:Organization
Organization Name:MAIN STREET PHARMACY 4 LLC
Other - Org Name:MAIN STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-870-9902
Mailing Address - Street 1:166 W BROAD ST
Mailing Address - Street 2:SUITE# G1
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3661
Mailing Address - Country:US
Mailing Address - Phone:203-883-8700
Mailing Address - Fax:203-883-8702
Practice Address - Street 1:166 W BROAD ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3661
Practice Address - Country:US
Practice Address - Phone:203-870-9902
Practice Address - Fax:203-870-9903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336S0011X
CTPCY.00021853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0722062OtherNCPDP PROVIDER IDENTIFICATION NUMBER