Provider Demographics
NPI:1669068649
Name:TEDEROUS, JOHN SR
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:TEDEROUS
Suffix:SR
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 1:69 WELCHS LN
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-5424
Mailing Address - Country:US
Mailing Address - Phone:207-608-3747
Mailing Address - Fax:
Practice Address - Street 1:800 MAIN ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-3500
Practice Address - Country:US
Practice Address - Phone:207-324-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR3980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist