Provider Demographics
NPI:1720504509
Name:VAILLANCOURT, AMY LYNNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNNE
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-0221
Mailing Address - Country:US
Mailing Address - Phone:207-449-9060
Mailing Address - Fax:
Practice Address - Street 1:194 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1428
Practice Address - Country:US
Practice Address - Phone:207-834-1690
Practice Address - Fax:207-834-1691
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR46755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPR46755OtherMAINE BOARD OF PHARMACY