Provider Demographics
NPI:1649579004
Name:RICKETT, JILL AMANDA
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:AMANDA
Last Name:RICKETT
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 1:2 PAIGE DR
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-2155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:226 PARKER FARM RD
Practice Address - Street 2:
Practice Address - City:BUXTON
Practice Address - State:ME
Practice Address - Zip Code:04093-3150
Practice Address - Country:US
Practice Address - Phone:207-727-5139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5661183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist