Provider Demographics
NPI:1033712807
Name:DAIGLE, KELLIE (RPH)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:DAIGLE
Suffix:
Gender:F
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:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:ME
Mailing Address - Zip Code:04457-0515
Mailing Address - Country:US
Mailing Address - Phone:207-356-2011
Mailing Address - Fax:
Practice Address - Street 1:22 GODING AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ME
Practice Address - Zip Code:04457-1323
Practice Address - Country:US
Practice Address - Phone:207-356-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4863183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist