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Organization
MAIN STREET PHARMACY 3 LLC
Active
Organization
MAIN STREET PHARMACY 3 LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JEAN K. JACOB PHARM. D (OWNER)
20321238001
Entity
Organization
Contact information
Practice address
2117 BOSTON AVE, BRIDGEPORT, CT 06610-3030
(203) 212-3800
(203) 212-3802
Mailing address
2117 BOSTON AVE, BRIDGEPORT, CT 06610-3030
(203) 212-3800
(203) 212-3802
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
—
CT
333600000X
Pharmacy
Primary
PCY2190
CT
3336C0003X
Community/Retail Pharmacy
—
—
3336C0004X
Compounding Pharmacy
—
—
3336S0011X
Specialty Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
008032995
—
CT
Enumeration date
11/24/2010
Last updated
03/09/2015
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