Provider Demographics
NPI:1205422334
Name:CAOUETTE, LEO
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:CAOUETTE
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 1:25 CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2103
Mailing Address - Country:US
Mailing Address - Phone:207-450-0211
Mailing Address - Fax:
Practice Address - Street 1:111 OSSIPEE TRL E
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:ME
Practice Address - Zip Code:04084-6464
Practice Address - Country:US
Practice Address - Phone:207-642-5544
Practice Address - Fax:207-642-4410
Is Sole Proprietor?:No
Enumeration Date:2020-12-13
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4764183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist