Organization
MAIN STREET PHARMACY LLC
Active
Other names
Main Street Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JEAN JACOB (OWNER)
(914) 843-1881
Entity
Organization
Contact information
Practice address
1005 MAIN ST # 1J, BRIDGEPORT, CT 06604-4221
(203) 870-9901
(203) 870-9903
Mailing address
1005 MAIN ST # 1J, BRIDGEPORT, CT 06604-4221
(203) 870-9901
(203) 870-9903
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PCY0002147
CT
3336C0004X
Compounding Pharmacy
—
—
3336S0011X
Specialty Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0721577
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
09/04/2009
Last updated
11/12/2010
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