Provider Demographics
NPI:1609356559
Name:NORTHUP, CASEY MARIE
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:MARIE
Last Name:NORTHUP
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 1:22 JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04443-6213
Mailing Address - Country:US
Mailing Address - Phone:207-343-1757
Mailing Address - Fax:
Practice Address - Street 1:360 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3900
Practice Address - Country:US
Practice Address - Phone:207-907-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPI46330183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician