Provider Demographics
NPI:1871670745
Name:CANAAN APOTHECARY LLC
Entity Type:Organization
Organization Name:CANAAN APOTHECARY LLC
Other - Org Name:CANAAN APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-435-4006
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06068-0566
Mailing Address - Country:US
Mailing Address - Phone:860-435-4006
Mailing Address - Fax:860-435-4604
Practice Address - Street 1:11 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06018-2509
Practice Address - Country:US
Practice Address - Phone:860-824-8000
Practice Address - Fax:860-824-7864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCY19783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004264587Medicaid
0720676OtherNCPDP PROVIDER IDENTIFICATION NUMBER