Provider Demographics
NPI:1770645491
Name:PRESQUE ISLE PHARMACY CO., LLC
Entity Type:Organization
Organization Name:PRESQUE ISLE PHARMACY CO., LLC
Other - Org Name:PRESQUE ISLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KAILEE
Authorized Official - Middle Name:S
Authorized Official - Last Name:STILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-760-9100
Mailing Address - Street 1:797 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-2201
Mailing Address - Country:US
Mailing Address - Phone:207-760-9100
Mailing Address - Fax:
Practice Address - Street 1:797 MAIN ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-2201
Practice Address - Country:US
Practice Address - Phone:207-760-9100
Practice Address - Fax:207-760-9191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-16
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
MEPH500013513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME134660000Medicaid
2007436OtherOTHER ID NUMBER
ME=========Medicaid
ME134660000Medicaid