Provider Demographics
NPI:1831337088
Name:SPRUCE MOUNTAIN PHARMACY INC.
Entity type:Organization
Organization Name:SPRUCE MOUNTAIN PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:207-645-5058
Mailing Address - Street 1:148 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:ME
Mailing Address - Zip Code:04239-1506
Mailing Address - Country:US
Mailing Address - Phone:207-897-9080
Mailing Address - Fax:207-897-9082
Practice Address - Street 1:148 MAIN ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:ME
Practice Address - Zip Code:04239-1506
Practice Address - Country:US
Practice Address - Phone:207-897-9080
Practice Address - Fax:207-897-9082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-27
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPH500013563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433815200Medicaid
ME6239740001Medicare NSC