Provider Demographics
NPI:1184210825
Name:VENTRELLA, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:VENTRELLA
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 1:15 JAY PLAZA LN
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:ME
Mailing Address - Zip Code:04239-5095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 JAY PLAZA LN
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:ME
Practice Address - Zip Code:04239-5095
Practice Address - Country:US
Practice Address - Phone:207-897-7033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR46043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist