Provider Demographics
NPI:1336627785
Name:BRICKER, TIFFANY M
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:BRICKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 CAPITOL ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-6232
Mailing Address - Country:US
Mailing Address - Phone:207-623-1170
Mailing Address - Fax:207-621-2346
Practice Address - Street 1:165 CAPITOL ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-6232
Practice Address - Country:US
Practice Address - Phone:207-623-1170
Practice Address - Fax:207-621-2346
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-29
Last Update Date:2018-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5213183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist