Provider Demographics
NPI:1376855874
Name:DECOSTA, ANTHONY JOSEPH (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JOSEPH
Last Name:DECOSTA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1415
Mailing Address - Country:US
Mailing Address - Phone:207-989-6238
Mailing Address - Fax:207-989-3267
Practice Address - Street 1:422 WILSON ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1415
Practice Address - Country:US
Practice Address - Phone:207-989-6238
Practice Address - Fax:207-989-3267
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5914183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist