Provider Demographics
NPI:1982120333
Name:SALEM PHARMACY LLC
Entity type:Organization
Organization Name:SALEM PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKOLINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-949-8624
Mailing Address - Street 1:20 HARTFORD RD STE 16
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:CT
Mailing Address - Zip Code:06420-3800
Mailing Address - Country:US
Mailing Address - Phone:860-949-8624
Mailing Address - Fax:860-949-8646
Practice Address - Street 1:20 HARTFORD RD STE 16
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:CT
Practice Address - Zip Code:06420-3800
Practice Address - Country:US
Practice Address - Phone:860-949-8624
Practice Address - Fax:860-949-8646
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SALEM PHARMACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCY22523336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008042535Medicaid