Provider Demographics
NPI:1982988713
Name:O'CONNOR, MARILYN CHRISTINE (RPH)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:CHRISTINE
Last Name:O'CONNOR
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 1:271 DEERFIELD RIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MOHEGAN SUN BLVD
Practice Address - Street 2:WALGREENS
Practice Address - City:UNCASEVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382
Practice Address - Country:US
Practice Address - Phone:860-859-9764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0010292183500000X
MAPH23104183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPCT.0010292OtherRPH LICENSE
MAPH23104OtherRPH LICENSE