1871672469 NPI number — GUARDIAN PHARMACY OF MAINE, LLC

Table of content: (NPI 1871672469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871672469 NPI number — GUARDIAN PHARMACY OF MAINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN PHARMACY OF MAINE, LLC
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:
6
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:
1871672469
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
GUARDIAN PHARMACY OF MAINE DEPT 2374
Provider Second Line Business Mailing Address:
P.O. BOX 11407
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35246-2374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-810-0089
Provider Business Mailing Address Fax Number:
404-810-0094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 BUSINESS PKWY
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04011-7390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-373-9077
Provider Business Practice Location Address Fax Number:
207-373-9088
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OLAND
Authorized Official First Name:
COURTNEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
207-373-9077

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: CSP50001564 , 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: 3099413 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: CSP50001564 . This is a "PHARMACY LICENSE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: E100200569 . This is a "MEDICARE- MASS IMMUNIZATION" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 1871672469 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2007537 . This is a "NABP#" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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