Provider Demographics
NPI:1770543639
Name:TAKACH, MICHAEL (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:TAKACH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 OLDE FORT RD
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-1813
Mailing Address - Country:US
Mailing Address - Phone:207-329-9977
Mailing Address - Fax:
Practice Address - Street 1:16 OLDE FORT RD
Practice Address - Street 2:
Practice Address - City:CAPE ELIZABETH
Practice Address - State:ME
Practice Address - Zip Code:04107-1813
Practice Address - Country:US
Practice Address - Phone:207-329-9977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME4385183500000X
MER1372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist