Provider Demographics
NPI:1396154092
Name:JACQUES, CAROLYN MARIE (PHARMD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
Last Name:JACQUES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 WEBBER AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-4921
Mailing Address - Country:US
Mailing Address - Phone:207-240-7491
Mailing Address - Fax:
Practice Address - Street 1:403 WATER ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-4667
Practice Address - Country:US
Practice Address - Phone:207-629-9401
Practice Address - Fax:207-629-9407
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR27860183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist