Organization
MY FAIR HAVEN PHARMACY LLC
Active
Other names
Fair Haven Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
MANTHENA V VARMA (MEMBER)
(203) 498-3479
Entity
Organization
Contact information
Practice address
72 GRAND AVE, NEW HAVEN, CT 06513
(203) 498-3479
(203) 498-8000
Mailing address
72 GRAND AVE, NEW HAVEN, CT 06513
(203) 498-3479
(203) 498-8000
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PCY.0002315
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
008061384
—
CT
01
—
008064135
MEDICAID DME
CT
Enumeration date
08/24/2015
Last updated
04/01/2016
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