Provider Demographics
NPI:1629301247
Name:LEBLANC, MARY J (RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 FORE RIVER PKWY STE 170
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2782
Mailing Address - Country:US
Mailing Address - Phone:207-535-1600
Mailing Address - Fax:207-535-1610
Practice Address - Street 1:195 FORE RIVER PKWY STE 170
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2782
Practice Address - Country:US
Practice Address - Phone:207-535-1600
Practice Address - Fax:207-535-1610
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17297183500000X
HIPH-1643183500000X
MEPR27756183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist