Provider Demographics
NPI:1245513415
Name:WILLARD, KATHRYN B
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:B
Last Name:WILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1093 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06241-2124
Mailing Address - Country:US
Mailing Address - Phone:860-774-0490
Mailing Address - Fax:860-774-0483
Practice Address - Street 1:1093 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-2124
Practice Address - Country:US
Practice Address - Phone:860-774-0490
Practice Address - Fax:860-774-0483
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0009912183500000X
MA22063183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist