Provider Demographics
NPI:1255753869
Name:PHARMACY DIRECT DELIVERY LLC
Entity type:Organization
Organization Name:PHARMACY DIRECT DELIVERY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DUTEAU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:802-655-3544
Mailing Address - Street 1:434 HURRICANE LN STE 200
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-2073
Mailing Address - Country:US
Mailing Address - Phone:802-655-3544
Mailing Address - Fax:802-655-0123
Practice Address - Street 1:434 HURRICANE LN STE 200
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-2073
Practice Address - Country:US
Practice Address - Phone:802-655-3544
Practice Address - Fax:802-655-0123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033054333600000X
NHNR09903336L0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT038.0134046OtherSTATE LICENSE
NHNR0990OtherSTATE LICENSE
VT1022646Medicaid
2143851OtherPK
NY06454686Medicaid
NY033054OtherSTATE LICENSE
NH3095901Medicaid