Provider Demographics
NPI:1932746591
Name:NUTMEG PHARMACY MOODUS LLC
Entity Type:Organization
Organization Name:NUTMEG PHARMACY MOODUS LLC
Other - Org Name:NUTMEG PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:860-345-3607
Mailing Address - Street 1:PO BOX 540
Mailing Address - Street 2:
Mailing Address - City:HIGGANUM
Mailing Address - State:CT
Mailing Address - Zip Code:06441-0540
Mailing Address - Country:US
Mailing Address - Phone:860-345-3607
Mailing Address - Fax:
Practice Address - Street 1:26 FALLS RD
Practice Address - Street 2:
Practice Address - City:MOODUS
Practice Address - State:CT
Practice Address - Zip Code:06469-1262
Practice Address - Country:US
Practice Address - Phone:860-891-8164
Practice Address - Fax:860-891-8313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-03
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008092217Medicaid