Provider Demographics
NPI:1790824571
Name:MILBRIDGE PHARMACY INC
Entity Type:Organization
Organization Name:MILBRIDGE PHARMACY INC
Other - Org Name:MILBRIDGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:
Authorized Official - Last Name:BELANGER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:207-546-2304
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:MILBRIDGE
Mailing Address - State:ME
Mailing Address - Zip Code:04658-0458
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MILBRIDGE
Practice Address - State:ME
Practice Address - Zip Code:04658-0458
Practice Address - Country:US
Practice Address - Phone:207-546-2304
Practice Address - Fax:207-546-2305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336L0003X, 3336M0002X
MEPH500007333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME127150000Medicaid
2036581OtherPK
ME127150000Medicaid