Provider Demographics
NPI:1942983184
Name:GAGNON, ETHAN CLARENCE
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:CLARENCE
Last Name:GAGNON
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 1:301 OAK GROVE AVE APT 25
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:ME
Mailing Address - Zip Code:04530-2372
Mailing Address - Country:US
Mailing Address - Phone:207-380-7153
Mailing Address - Fax:
Practice Address - Street 1:125 TOPSHAM FAIR MALL RD
Practice Address - Street 2:
Practice Address - City:TOPSHAM
Practice Address - State:ME
Practice Address - Zip Code:04086-1741
Practice Address - Country:US
Practice Address - Phone:207-504-5051
Practice Address - Fax:207-504-5396
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPI71263183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician