Provider Demographics
NPI:1184645921
Name:ST JOHN VALLEY PHARMACY LLC
Entity Type:Organization
Organization Name:ST JOHN VALLEY PHARMACY LLC
Other - Org Name:ST JOHN VALLEY LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:OUELLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-834-2880
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-0189
Mailing Address - Country:US
Mailing Address - Phone:207-834-2881
Mailing Address - Fax:
Practice Address - Street 1:182 MARKET ST STE 3
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1514
Practice Address - Country:US
Practice Address - Phone:207-834-2880
Practice Address - Fax:207-834-2882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MEPH500012403336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2037589OtherPK
ME1184645921Medicaid
2037589OtherPK