Provider Demographics
NPI:1518379528
Name:KLOTZ, SIEGFRIED ALFRED
Entity Type:Individual
Prefix:
First Name:SIEGFRIED
Middle Name:ALFRED
Last Name:KLOTZ
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 1:1046 LEE RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:ME
Mailing Address - Zip Code:04457-4812
Mailing Address - Country:US
Mailing Address - Phone:207-794-3344
Mailing Address - Fax:207-794-8975
Practice Address - Street 1:2 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ME
Practice Address - Zip Code:04457-1247
Practice Address - Country:US
Practice Address - Phone:207-794-3344
Practice Address - Fax:207-794-8975
Is Sole Proprietor?:No
Enumeration Date:2014-05-25
Last Update Date:2014-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR12596183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist