Provider Demographics
NPI:1154649002
Name:POULIN, ROGER ROLAND (RPH)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:ROLAND
Last Name:POULIN
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 1:34 PINE DR
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:ME
Mailing Address - Zip Code:04084-5217
Mailing Address - Country:US
Mailing Address - Phone:207-892-0874
Mailing Address - Fax:
Practice Address - Street 1:19 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009-1229
Practice Address - Country:US
Practice Address - Phone:207-647-3445
Practice Address - Fax:207-647-2086
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-16
Last Update Date:2010-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR3716183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist