Provider Demographics
NPI:1760012744
Name:THERIAULT, CYNTHIA MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARIE
Last Name:THERIAULT
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 1:1171 US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-5837
Mailing Address - Country:US
Mailing Address - Phone:207-351-9010
Mailing Address - Fax:207-351-9011
Practice Address - Street 1:1171 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-5837
Practice Address - Country:US
Practice Address - Phone:207-351-9010
Practice Address - Fax:207-351-9011
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-18
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5547183500000X
MAPH23560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist