Provider Demographics
NPI:1780900233
Name:CANDLEWOOD DRUGS
Entity type:Organization
Organization Name:CANDLEWOOD DRUGS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
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:203-312-9999
Mailing Address - Street 1:11 STATE ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:NEW FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06812-4028
Mailing Address - Country:US
Mailing Address - Phone:203-312-9999
Mailing Address - Fax:203-746-6789
Practice Address - Street 1:11 STATE ROUTE 37
Practice Address - Street 2:
Practice Address - City:NEW FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06812-4028
Practice Address - Country:US
Practice Address - Phone:203-312-9999
Practice Address - Fax:203-746-6789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0002167332B00000X
CTPCY.00021673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008017664Medicaid
CTPCY.0002167OtherSTATE BOARD LICENSE NUMBER
CT008017664Medicaid