Provider Demographics
NPI:1912629437
Name:STUART, CORDELL (RPH)
Entity Type:Individual
Prefix:
First Name:CORDELL
Middle Name:
Last Name:STUART
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 1:218 TEMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-1223
Mailing Address - Country:US
Mailing Address - Phone:207-712-0830
Mailing Address - Fax:
Practice Address - Street 1:465 MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4328
Practice Address - Country:US
Practice Address - Phone:207-854-9103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR71176183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist