Provider Demographics
NPI:1891171393
Name:POUSSARD, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:POUSSARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 CHINA RD
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:ME
Mailing Address - Zip Code:04901-7246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 CHINA RD
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:ME
Practice Address - Zip Code:04901-7246
Practice Address - Country:US
Practice Address - Phone:207-872-2728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR45415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist