Provider Demographics
NPI:1033758651
Name:BOATENG, KWAKU D
Entity Type:Individual
Prefix:
First Name:KWAKU
Middle Name:D
Last Name:BOATENG
Suffix:
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 1:19 EVANTHIA DR
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9722
Mailing Address - Country:US
Mailing Address - Phone:508-615-0356
Mailing Address - Fax:
Practice Address - Street 1:400 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-1650
Practice Address - Country:US
Practice Address - Phone:207-363-4312
Practice Address - Fax:207-363-4986
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR69236183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist