Provider Demographics
NPI:1851317705
Name:BEACON FALLS PHARMACY, LLC
Entity Type:Organization
Organization Name:BEACON FALLS PHARMACY, LLC
Other - Org Name:BEACON FALLS PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-729-4567
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:BEACON FALLS
Mailing Address - State:CT
Mailing Address - Zip Code:06403-0218
Mailing Address - Country:US
Mailing Address - Phone:203-729-4567
Mailing Address - Fax:203-729-4573
Practice Address - Street 1:20 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEACON FALLS
Practice Address - State:CT
Practice Address - Zip Code:06403-1131
Practice Address - Country:US
Practice Address - Phone:203-729-4567
Practice Address - Fax:203-729-4573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CTPCY20153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004253548Medicaid
2002743OtherPK
2002743OtherPK