Provider Demographics
NPI:1154895837
Name:MAIN STREET PHARMACY INC
Entity type:Organization
Organization Name:MAIN STREET PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAVEENDRA
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:BOMMU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-919-3124
Mailing Address - Street 1:421 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1534
Mailing Address - Country:US
Mailing Address - Phone:860-200-0909
Mailing Address - Fax:860-200-0707
Practice Address - Street 1:421 PARK ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1534
Practice Address - Country:US
Practice Address - Phone:860-200-0909
Practice Address - Fax:860-200-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy