Main Street Pharmacy 3 LLC

Primary specialty

PharmacyTaxonomy code 333600000X

License

PCY2190 Issued in CT

Legal business name

MAIN STREET PHARMACY 3 LLC

Practice address

2117 Boston Ave
Bridgeport, CT 06610-3030

Phone

(203) 212-3800

Fax

(203) 212-3802

NPI assigned

Nov 24, 2010

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Jean K. Jacob, PHARM. DNPI 1417280652

Title

Owner

Phone

20321238001

Specialties & licenses 6

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in CT2 enrollments

Enrollment records 2

Tax ID family

Main Street Pharmacy 3 LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Main Street Pharmacy 3 LLC

  • Long Term Care Pharmacy
  • Bridgeport, CT
  • NPI 1780182766
  NPD tax ID

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jean K Jacob, PHARM.D.

  • Pharmacist
  • Bridgeport, CT
  • NPI 1417280652
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1290556800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1425859200000",
    "number": "1316249352",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2117 BOSTON AVE",
            "city": "BRIDGEPORT",
            "state": "CT",
            "postal_code": "066103030",
            "telephone_number": "203-212-3800",
            "fax_number": "203-212-3802"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2117 BOSTON AVE",
            "city": "BRIDGEPORT",
            "state": "CT",
            "postal_code": "066103030",
            "telephone_number": "203-212-3800",
            "fax_number": "203-212-3802"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAIN STREET PHARMACY 3 LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-11-24",
        "last_updated": "2015-03-09",
        "status": "A",
        "authorized_official_last_name": "JACOB",
        "authorized_official_first_name": "JEAN",
        "authorized_official_middle_name": "K.",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "20321238001",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHARM. D"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332BP3500X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies, Parenteral & Enteral Nutrition",
            "state": "CT",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "CT",
            "license": "PCY2190",
            "primary": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0004X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Compounding Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336S0011X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Specialty Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "008032995",
            "state": "CT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Emily Mai, PHARMD
• Adriana Maia, APRN, FNP-C
• Fritz Maignan, MS, NCC, LPC
• Jackson P Maille, MD
• Main Street Pediatrics, PC
• Main Street Pharmacy 3 LLC
• Main Street Pharmacy LLC
• Kenneth Joseph Maiocco, M.D.
• Melinda Joan Maisano
• Jonathan Maisel, MD

• Pharmacy in Bridgeport, CT
• Providers in Bridgeport, CT by specialty
• Pharmacy in Connecticut

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 9, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.