Provider Demographics
NPI:1356554190
Name:WATERVILLE PHARMACY
Entity type:Organization
Organization Name:WATERVILLE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RHP
Authorized Official - Phone:207-453-4411
Mailing Address - Street 1:50 W CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6007
Mailing Address - Country:US
Mailing Address - Phone:207-453-4411
Mailing Address - Fax:207-453-6612
Practice Address - Street 1:50 W CONCOURSE
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6007
Practice Address - Country:US
Practice Address - Phone:207-453-4411
Practice Address - Fax:207-453-6612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPH50001305183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPH50001305OtherPHARMACY LICENSE NUMBER
FW0238003OtherDEA LICENSE NUMBER