Provider Demographics
NPI:1790855419
Name:DRUST MARKETS LLC
Entity Type:Organization
Organization Name:DRUST MARKETS LLC
Other - Org Name:SHOPRITE OF WALLINGFORD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8439
Mailing Address - Street 1:PO BOX 15169
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07192-5169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:846 N COLONY RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2410
Practice Address - Country:US
Practice Address - Phone:203-626-7765
Practice Address - Fax:203-626-7767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CTPCY00013553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0713164OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CT004089480Medicaid
0713164OtherNCPDP PROVIDER IDENTIFICATION NUMBER