Provider Demographics
NPI:1447898523
Name:BEACON PHARMACY LLC
Entity type:Organization
Organization Name:BEACON PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MAYUR
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-292-8200
Mailing Address - Street 1:42 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-2438
Mailing Address - Country:US
Mailing Address - Phone:860-875-9263
Mailing Address - Fax:
Practice Address - Street 1:42 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-2438
Practice Address - Country:US
Practice Address - Phone:860-875-9263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008043533Medicaid