Provider Demographics
NPI:1730423195
Name:WILMOT, ROGER GOODWIN JR
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:GOODWIN
Last Name:WILMOT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 MCALISTER FARM RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-5946
Mailing Address - Country:US
Mailing Address - Phone:207-775-0631
Mailing Address - Fax:
Practice Address - Street 1:97 MCALISTER FARM RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-5946
Practice Address - Country:US
Practice Address - Phone:207-775-0631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR28591835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric