Provider Demographics
NPI:1396815106
Name:MAINEHEALTH
Entity Type:Organization
Organization Name:MAINEHEALTH
Other - Org Name:THE PHARMACY AT PEN BAY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL COO
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-563-4597
Mailing Address - Street 1:ATTN: RETAIL PHARMACY
Mailing Address - Street 2:6 GLEN COVE DRIVE
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856
Mailing Address - Country:US
Mailing Address - Phone:207-921-8585
Mailing Address - Fax:207-921-5274
Practice Address - Street 1:ATTN: RETAIL PHARMACY
Practice Address - Street 2:6 GLEN COVE DRIVE
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856
Practice Address - Country:US
Practice Address - Phone:207-921-8585
Practice Address - Fax:207-921-5274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MEPH500010803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2037448OtherPK
ME1396815106Medicaid
ME=========Medicaid