Provider Demographics
NPI:1811140841
Name:COASTAL PHARMACY LLC
Entity type:Organization
Organization Name:COASTAL PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:CASSI
Authorized Official - Middle Name:Q
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-899-0886
Mailing Address - Street 1:29 MARGINAL WAY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-1914
Mailing Address - Country:US
Mailing Address - Phone:207-899-0886
Mailing Address - Fax:207-899-0826
Practice Address - Street 1:29 MARGINAL WAY
Practice Address - Street 2:SUITE 4
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1914
Practice Address - Country:US
Practice Address - Phone:207-899-0886
Practice Address - Fax:207-899-0826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336C0004X
MEPH500015313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1811140841Medicaid
2153871OtherPK