Provider Demographics
NPI:1780689836
Name:MASONIC HEALTHCARE CENTER
Entity Type:Organization
Organization Name:MASONIC HEALTHCARE CENTER
Other - Org Name:PHARMACY DEPARTMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:DEFLORIO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:203-679-6928
Mailing Address - Street 1:22 MASONIC AVE
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3048
Mailing Address - Country:US
Mailing Address - Phone:203-679-6928
Mailing Address - Fax:203-679-5970
Practice Address - Street 1:22 MASONIC AVE
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-3048
Practice Address - Country:US
Practice Address - Phone:203-679-6928
Practice Address - Fax:203-679-5970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT119-C314000000X
CT119C3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTAM2390324OtherDEA NUMBER