Provider Demographics
NPI:1134808256
Name:IRADUHA, FABRICE
Entity type:Individual
Prefix:DR
First Name:FABRICE
Middle Name:
Last Name:IRADUHA
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 1:72 PURCHAS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1152
Mailing Address - Country:US
Mailing Address - Phone:207-560-7541
Mailing Address - Fax:
Practice Address - Street 1:30 LANDING RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5560
Practice Address - Country:US
Practice Address - Phone:207-893-0603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR71575183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist