Provider Demographics
NPI:1174807002
Name:PROCARE LTC PHARMACY OF CONNECTICUT LLC
Entity type:Organization
Organization Name:PROCARE LTC PHARMACY OF CONNECTICUT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:DR
Authorized Official - First Name:BINCY
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGHESE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:888-741-0367
Mailing Address - Street 1:1 OLYMPIC PL STE 600
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-4110
Mailing Address - Country:US
Mailing Address - Phone:877-741-0367
Mailing Address - Fax:
Practice Address - Street 1:1492 HIGHLAND AVE STE 1C
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-1287
Practice Address - Country:US
Practice Address - Phone:203-439-9099
Practice Address - Fax:631-963-3990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPHN110413336L0003X
NY031744333600000X
CTPCY00022143336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT02869827Medicaid
2132865OtherPK
6975550001Medicare NSC