Provider Demographics
NPI:1649251372
Name:BUNKER HILL PHARMACY INC
Entity type:Organization
Organization Name:BUNKER HILL PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:203-574-7825
Mailing Address - Street 1:256 BUNKER HILL AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2253
Mailing Address - Country:US
Mailing Address - Phone:203-574-7825
Mailing Address - Fax:203-574-4972
Practice Address - Street 1:256 BUNKER HILL AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2253
Practice Address - Country:US
Practice Address - Phone:203-574-7825
Practice Address - Fax:203-574-4972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 332B00000X, 333600000X, 3336C0004X
CTPCY.00002743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004027306Medicaid
CT004016036Medicaid
1998233OtherPK
0127770001Medicare NSC