Provider Demographics
NPI:1154733897
Name:SIDHOM, SALLY
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:SIDHOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ARROWHEAD DR
Mailing Address - Street 2:UNIT 7
Mailing Address - City:VASSALBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04989-4043
Mailing Address - Country:US
Mailing Address - Phone:603-560-2887
Mailing Address - Fax:
Practice Address - Street 1:35 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-8160
Practice Address - Country:US
Practice Address - Phone:603-560-2887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5903183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist