Provider Demographics
NPI:1225628514
Name:MENTAG, PAUL JEROME
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JEROME
Last Name:MENTAG
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 1:17 BAILEY FARM RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-5808
Mailing Address - Country:US
Mailing Address - Phone:207-869-5833
Mailing Address - Fax:
Practice Address - Street 1:17 BAILEY FARM RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-5808
Practice Address - Country:US
Practice Address - Phone:207-869-5833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician