1831337088 NPI number — SPRUCE MOUNTAIN PHARMACY INC.

Table of content: (NPI 1831337088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831337088 NPI number — SPRUCE MOUNTAIN PHARMACY INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRUCE MOUNTAIN PHARMACY INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831337088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
148 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAY
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04239-1506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-897-9080
Provider Business Mailing Address Fax Number:
207-897-9082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
148 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAY
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04239-1506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-897-9080
Provider Business Practice Location Address Fax Number:
207-897-9082
Provider Enumeration Date:
01/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MAKI
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/PHARMACIST
Authorized Official Telephone Number:
207-645-5058

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH50001356 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 433815200 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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