Provider Demographics
NPI:1063445625
Name:KENNEBEC PHARMACY AND HOME CARE LLC
Entity Type:Organization
Organization Name:KENNEBEC PHARMACY AND HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GM
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCVETY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-626-2726
Mailing Address - Street 1:43 LEIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-7705
Mailing Address - Country:US
Mailing Address - Phone:207-626-2726
Mailing Address - Fax:207-729-2704
Practice Address - Street 1:121 MEDICAL CENTER DR
Practice Address - Street 2:STE G500
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2653
Practice Address - Country:US
Practice Address - Phone:207-729-3642
Practice Address - Fax:207-729-2704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BX2000X
MEPH50001463333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000951OtherNCPDP PROVIDER IDENTIFICATION NUMBER
ME110020000Medicaid