Basic Information
| Provider Information | |||||||||
| NPI: | 1508051921 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GAYLORD HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GAYLORD HOSPITAL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 GAYLORD FARM RD | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064927048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032842800 | ||||||||
| FaxNumber: | 2032842998 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 GAYLORD FARM RD | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064927048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032842800 | ||||||||
| FaxNumber: | 2032842998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 09/21/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALBERTI | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 2032943218 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | CSP.0012032 | CT | Y | Suppliers | Pharmacy | Institutional Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1999529 | 01 | PK | OTHER |