Provider Demographics
NPI:1780274670
Name:ELLEGARD, BERNADETTE O'BRIEN (RPH)
Entity type:Individual
Prefix:MS
First Name:BERNADETTE
Middle Name:O'BRIEN
Last Name:ELLEGARD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:CT
Mailing Address - Zip Code:06757-0373
Mailing Address - Country:US
Mailing Address - Phone:203-240-1900
Mailing Address - Fax:
Practice Address - Street 1:80 N MAIN ST UNIT 36
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:CT
Practice Address - Zip Code:06757-1523
Practice Address - Country:US
Practice Address - Phone:203-240-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034215183500000X
CTPCT.0010997183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist