Provider Demographics
NPI:1558762971
Name:CONNECTICUT PHARMACY OF MADISON LLC
Entity type:Organization
Organization Name:CONNECTICUT PHARMACY OF MADISON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-518-1146
Mailing Address - Street 1:11 BISHOP RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06478-1597
Mailing Address - Country:US
Mailing Address - Phone:203-888-5454
Mailing Address - Fax:203-828-6236
Practice Address - Street 1:200 BOSTON POST RD STE 9
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2144
Practice Address - Country:US
Practice Address - Phone:203-421-2132
Practice Address - Fax:203-421-2135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-05
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X, 3336S0011X
CTPCY00023003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147371OtherPK