Provider Demographics
NPI:1750707725
Name:PROSPECT PHARMACY LLC
Entity type:Organization
Organization Name:PROSPECT PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MISS
Authorized Official - First Name:SIRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLIDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-758-1111
Mailing Address - Street 1:166 WATERBURY RD
Mailing Address - Street 2:302
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1200
Mailing Address - Country:US
Mailing Address - Phone:203-758-1111
Mailing Address - Fax:203-758-1122
Practice Address - Street 1:166 WATERBURY RD
Practice Address - Street 2:302
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1200
Practice Address - Country:US
Practice Address - Phone:203-758-1111
Practice Address - Fax:203-758-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy