Provider Demographics
NPI:1932203510
Name:LUPES DRUG STORE INC
Entity Type:Organization
Organization Name:LUPES DRUG STORE INC
Other - Org Name:LUPES DRUG STORE OF FAIRFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-368-1955
Mailing Address - Street 1:2035 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3550
Mailing Address - Country:US
Mailing Address - Phone:203-368-1955
Mailing Address - Fax:203-384-2551
Practice Address - Street 1:2035 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3550
Practice Address - Country:US
Practice Address - Phone:203-368-1955
Practice Address - Fax:203-384-2551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
CTPCY.00008603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1998247OtherPK
CT004030771Medicaid
CT004017943Medicaid
1998247OtherPK
0381560001Medicare NSC