Provider Demographics
NPI:1417558198
Name:PELLETIER, JOHNNA
Entity Type:Individual
Prefix:
First Name:JOHNNA
Middle Name:
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04462-0346
Mailing Address - Country:US
Mailing Address - Phone:207-712-7327
Mailing Address - Fax:
Practice Address - Street 1:843 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:MILLINOCKET
Practice Address - State:ME
Practice Address - Zip Code:04462-2125
Practice Address - Country:US
Practice Address - Phone:207-723-8148
Practice Address - Fax:207-723-9548
Is Sole Proprietor?:No
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR6056183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist