Provider Demographics
NPI:1568643401
Name:LOCKE, KEVIN M
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:LOCKE
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 1:2 MARINE DR
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-1022
Mailing Address - Country:US
Mailing Address - Phone:781-710-5802
Mailing Address - Fax:
Practice Address - Street 1:2 MARINE DR
Practice Address - Street 2:
Practice Address - City:OLD ORCHARD BEACH
Practice Address - State:ME
Practice Address - Zip Code:04064-1022
Practice Address - Country:US
Practice Address - Phone:781-710-5802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5378183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist