Provider Demographics
NPI:1699253021
Name:MATHIESON, MEGAN
Entity type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:
Last Name:MATHIESON
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 1:24 STONE ST STE 120
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5209
Mailing Address - Country:US
Mailing Address - Phone:207-623-4181
Mailing Address - Fax:
Practice Address - Street 1:24 STONE ST STE 120
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5209
Practice Address - Country:US
Practice Address - Phone:207-623-4181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-28
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR12496183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist