Provider Demographics
NPI:1871672469
Name:GUARDIAN PHARMACY OF MAINE, LLC
Entity Type:Organization
Organization Name:GUARDIAN PHARMACY OF MAINE, LLC
Other - Org Name:WALTZ LONG TERM CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-373-9077
Mailing Address - Street 1:GUARDIAN PHARMACY OF MAINE DEPT 2374
Mailing Address - Street 2:P.O. BOX 11407
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-2374
Mailing Address - Country:US
Mailing Address - Phone:404-810-0089
Mailing Address - Fax:404-810-0094
Practice Address - Street 1:3 BUSINESS PKWY
Practice Address - Street 2:SUITE 2
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-7390
Practice Address - Country:US
Practice Address - Phone:207-373-9077
Practice Address - Fax:207-373-9088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MECSP500015643336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3099413Medicaid
MECSP50001564OtherPHARMACY LICENSE
MEE100200569OtherMEDICARE- MASS IMMUNIZATION
ME1871672469Medicaid
ME2007537OtherNABP#
NH3099413Medicaid