Basic Information
| Provider Information | |||||||||
| NPI: | 1770670572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNELLY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 FARMWOOD RD | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032245504 | ||||||||
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| Practice Location | |||||||||
| Address1: | 718 SMYTH RD. | ||||||||
| Address2: | VA MEDICAL CENTER | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036244366 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | R1492 | NH | Y | Pharmacy Service Providers | Pharmacist | 183500000X | 31565 | NY | N | Pharmacy Service Providers | Pharmacist |
No ID Information.