Provider Demographics
NPI:1245560853
Name:MAIN STREET PHARMACY 2 LLC
Entity type:Organization
Organization Name:MAIN STREET PHARMACY 2 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BUTURLA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:203-297-6130
Mailing Address - Street 1:345 MAIN ST STE 7
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5847
Mailing Address - Country:US
Mailing Address - Phone:203-297-6130
Mailing Address - Fax:203-297-6132
Practice Address - Street 1:345 MAIN ST STE 7
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5847
Practice Address - Country:US
Practice Address - Phone:203-297-6130
Practice Address - Fax:203-297-6132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-04
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0004X
CTPCY.0002154333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123385OtherPK
CT6424720001Medicare NSC