Provider Demographics
NPI:1861844300
Name:CENTRAL MAINE APOTHECARY VENTURES
Entity Type:Organization
Organization Name:CENTRAL MAINE APOTHECARY VENTURES
Other - Org Name:CMMC PHARMACY-CENTER ST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FORBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-795-2328
Mailing Address - Street 1:300 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7027
Mailing Address - Country:US
Mailing Address - Phone:207-784-0807
Mailing Address - Fax:207-784-0808
Practice Address - Street 1:593 CENTER ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-6323
Practice Address - Country:US
Practice Address - Phone:207-784-0807
Practice Address - Fax:207-784-0808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-08
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPH50001561333600000X
3336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162050OtherPK