Provider Demographics
NPI:1922041680
Name:HARTFORD PHARMACY LLC
Entity Type:Organization
Organization Name:HARTFORD PHARMACY LLC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:605-528-2000
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:SD
Mailing Address - Zip Code:57033-0397
Mailing Address - Country:US
Mailing Address - Phone:605-528-2000
Mailing Address - Fax:605-528-2003
Practice Address - Street 1:304 W. HIGHWAY 38
Practice Address - Street 2:SUITE 102
Practice Address - City:HARTFORD
Practice Address - State:SD
Practice Address - Zip Code:57033-0397
Practice Address - Country:US
Practice Address - Phone:605-528-2000
Practice Address - Fax:605-528-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD100-18733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8504260Medicaid
SD4353746OtherNCPDP #
SD4353746OtherNCPDP #
SDBM9274767OtherDEA #
SD8504260Medicaid