Provider Demographics
NPI:1962775726
Name:SHIRETOWN PHARMACY LLC
Entity type:Organization
Organization Name:SHIRETOWN PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:OUELLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-834-2880
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-0189
Mailing Address - Country:US
Mailing Address - Phone:207-532-5980
Mailing Address - Fax:207-532-5981
Practice Address - Street 1:101 MILITARY ST
Practice Address - Street 2:
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730-2511
Practice Address - Country:US
Practice Address - Phone:207-532-5980
Practice Address - Fax:207-532-5981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MEPH500014463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1962775726Medicaid
2133708OtherPK