Provider Demographics
NPI:1740617158
Name:PRATT, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PRATT
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 1:624 WILTON RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-6138
Mailing Address - Country:US
Mailing Address - Phone:207-778-5419
Mailing Address - Fax:207-778-5983
Practice Address - Street 1:624 WILTON ROAD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938
Practice Address - Country:US
Practice Address - Phone:207-778-5419
Practice Address - Fax:207-778-5983
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4922183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist