NPIMap

Organization Active NPI

Fair Haven Community Health Clinic Inc

  • Community/Retail Pharmacy
  • New Haven, CT
National Provider Identifier
1346984838
Registry record updated Nov 12, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
Legal business name
FAIR HAVEN COMMUNITY HEALTH CLINIC INC
Practice address
111 Grand Ave
New Haven, CT 06513-3907
Phone
(203) 777-7411
NPI assigned
Apr 21, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 12, 2024

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

Authorized official

Name
Bain Patrie
Title
Credentialing Manager
Phone
(203) 777-7411

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X Primary

Addresses

Primary practice location

111 Grand Ave
New Haven, CT 06513-3907

Mailing address

221 W Main St
Branford, CT 06405-4022
Phone (203) 871-4188

Other names 2

  • Fair Haven Community Health Care Doing business as
  • Grand Pharmacy 111 Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CT2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20240916002505 CT Part B Supplier - Pharmacy 4183511538 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: New Haven, CT; Branford, CT
O20250127000090 CT Part B Supplier - Mass Immunization (Roster Biller Only) 4183511538 Practice locations: Branford, CT; New Haven, CT

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Fair Haven Community10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

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

NPI Registry JSON

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

{
    "created_epoch": "1650499200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1731369600000",
    "number": "1346984838",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "221 W MAIN ST",
            "city": "BRANFORD",
            "state": "CT",
            "postal_code": "064054022",
            "telephone_number": "203-871-4188"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 GRAND AVE",
            "city": "NEW HAVEN",
            "state": "CT",
            "postal_code": "065133907",
            "telephone_number": "203-777-7411"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAIR HAVEN COMMUNITY HEALTH CLINIC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-04-21",
        "last_updated": "2024-11-12",
        "certification_date": "2024-11-12",
        "status": "A",
        "authorized_official_last_name": "PATRIE",
        "authorized_official_first_name": "BAIN",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "203-777-7411"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fair Haven Community Health Care",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Grand Pharmacy 111",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Grand Pharmacy 111",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in New Haven, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 12, 2024; 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.