Provider Demographics
NPI:1316601842
Name:MACOMBER, IAN A
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:A
Last Name:MACOMBER
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 1:115 WILLIAMS RD
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-5266
Mailing Address - Country:US
Mailing Address - Phone:207-450-4682
Mailing Address - Fax:
Practice Address - Street 1:112 BENNETT DR
Practice Address - Street 2:
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-2022
Practice Address - Country:US
Practice Address - Phone:207-498-8735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-31
Last Update Date:2021-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR69423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist