Provider Demographics
NPI:1770184426
Name:DAMON, MARIAH SUE
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:SUE
Last Name:DAMON
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 1:24 LIBBY LN
Mailing Address - Street 2:
Mailing Address - City:WEST GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-3230
Mailing Address - Country:US
Mailing Address - Phone:207-313-6652
Mailing Address - Fax:
Practice Address - Street 1:8 GURNET RD STE 1
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2766
Practice Address - Country:US
Practice Address - Phone:207-373-0310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-07
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR69378183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist