Provider Demographics
NPI:1114245560
Name:CLOUTIER DOSTAL, DIANE CLAIRE (RPH)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:CLAIRE
Last Name:CLOUTIER DOSTAL
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 1:461 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-1528
Mailing Address - Country:US
Mailing Address - Phone:207-284-4363
Mailing Address - Fax:207-284-8229
Practice Address - Street 1:461 MAIN ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1528
Practice Address - Country:US
Practice Address - Phone:207-284-4363
Practice Address - Fax:207-284-8229
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPR4357OtherPHARMACY LICENSE