Provider Demographics
NPI:1710070487
Name:VISELS DRUG STORE INC
Entity Type:Organization
Organization Name:VISELS DRUG STORE INC
Other - Org Name:VISELS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-562-6878
Mailing Address - Street 1:714 DIXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-1038
Mailing Address - Country:US
Mailing Address - Phone:203-562-6878
Mailing Address - Fax:203-624-3530
Practice Address - Street 1:714 DIXWELL AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-1038
Practice Address - Country:US
Practice Address - Phone:203-562-6878
Practice Address - Fax:203-624-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CTPCY00000893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004026233Medicaid
CT004015350Medicaid
1998384OtherPK
CT004015350Medicaid