Provider Demographics
NPI:1003542689
Name:PRIAM, NWANDO (RPH)
Entity Type:Individual
Prefix:
First Name:NWANDO
Middle Name:
Last Name:PRIAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CHESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3615
Mailing Address - Country:US
Mailing Address - Phone:347-768-0484
Mailing Address - Fax:
Practice Address - Street 1:51 MARKET ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3617
Practice Address - Country:US
Practice Address - Phone:207-799-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR46865183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist