Provider Demographics
NPI:1265547475
Name:HEBRON PHARMACY, INC.
Entity type:Organization
Organization Name:HEBRON PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAYDEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-228-3888
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:CT
Mailing Address - Zip Code:06248-0155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:CT
Practice Address - Zip Code:06248-1519
Practice Address - Country:US
Practice Address - Phone:860-228-3888
Practice Address - Fax:860-228-3391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CTPCY.00010623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0708137OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CT004031720Medicaid
CT004063095Medicaid
CT004031720Medicaid