Provider Demographics
NPI:1861433765
Name:CENTRAL MAINE MEDICAL CENTER
Entity type:Organization
Organization Name:CENTRAL MAINE MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUPKA
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTORATE
Authorized Official - Phone:207-795-8106
Mailing Address - Street 1:CMMC PHARMACY
Mailing Address - Street 2:300 MAIN STREET
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240
Mailing Address - Country:US
Mailing Address - Phone:207-795-7177
Mailing Address - Fax:207-795-7552
Practice Address - Street 1:12 HIGH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7676
Practice Address - Country:US
Practice Address - Phone:207-795-7177
Practice Address - Fax:207-795-7552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336S0011X, 333600000X
MEPH500014913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2037588OtherPK
ME1861433765Medicaid