Provider Demographics
NPI:1548622491
Name:CHURCHILL, KASSANDRA ALYSSA
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:ALYSSA
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1073 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOVER FOXCROFT
Mailing Address - State:ME
Mailing Address - Zip Code:04426-3742
Mailing Address - Country:US
Mailing Address - Phone:207-564-2857
Mailing Address - Fax:207-564-3278
Practice Address - Street 1:1073 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426-3742
Practice Address - Country:US
Practice Address - Phone:207-564-2857
Practice Address - Fax:207-564-3278
Is Sole Proprietor?:No
Enumeration Date:2016-03-21
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR45347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist