Provider Demographics
NPI:1932236775
Name:SUBURBAN PHARMACY LTC INC
Entity Type:Organization
Organization Name:SUBURBAN PHARMACY LTC INC
Other - Org Name:SUBURBAN PHARMACY LTC INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SATISH
Authorized Official - Middle Name:
Authorized Official - Last Name:ANNAMANENI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:860-882-1808
Mailing Address - Street 1:342 N MAIN ST
Mailing Address - Street 2:STE 70
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2500
Mailing Address - Country:US
Mailing Address - Phone:860-882-1808
Mailing Address - Fax:860-882-1791
Practice Address - Street 1:342 N MAIN ST
Practice Address - Street 2:STE 70
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2500
Practice Address - Country:US
Practice Address - Phone:860-882-1808
Practice Address - Fax:860-882-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
CT20513336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0720690OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0720690OtherNCPDP PROVIDER IDENTIFICATION NUMBER