Provider Demographics
NPI:1881961589
Name:NEW ALBERTSON'S INC #7557/490
Entity type:Organization
Organization Name:NEW ALBERTSON'S INC #7557/490
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:207-669-3005
Mailing Address - Street 1:175 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-1730
Mailing Address - Country:US
Mailing Address - Phone:207-669-3005
Mailing Address - Fax:207-669-3013
Practice Address - Street 1:175 HIGH ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1730
Practice Address - Country:US
Practice Address - Phone:207-669-3005
Practice Address - Fax:207-669-3013
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW ALBERTSON'S INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR46153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy