Provider Demographics
NPI:1134184260
Name:MARY E TYRRELL
Entity type:Organization
Organization Name:MARY E TYRRELL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:TYRRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-263-2018
Mailing Address - Street 1:2 MAIN ST N
Mailing Address - Street 2:P.O. BOX 363
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-2950
Mailing Address - Country:US
Mailing Address - Phone:203-263-2018
Mailing Address - Fax:
Practice Address - Street 1:2 MAIN ST N
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-2950
Practice Address - Country:US
Practice Address - Phone:203-263-2018
Practice Address - Fax:203-263-7244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004069845Medicaid