Provider Demographics
NPI:1689119000
Name:KIWAK, DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KIWAK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-2033
Mailing Address - Country:US
Mailing Address - Phone:207-854-6400
Mailing Address - Fax:207-854-6401
Practice Address - Street 1:39 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2033
Practice Address - Country:US
Practice Address - Phone:207-854-6400
Practice Address - Fax:207-854-6401
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4395183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist