MEDICARE: HANNAFORD BROS CO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy	PH50000794	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2036818	OTHER		PK

General Provider Information

NPI Number	:	1558479949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HANNAFORD BROS CO LLC

Provider Business Mailing Address
First Line	:	PO BOX 1000
Second Line	:	MS 3000
City	:	PORTLAND
State	:	ME
Zip	:	04104-5005
Country	:	US
Telephone Number	:	207-885-7454
Fax Number	:	704-645-6531

Provider Business Practice Location Address
First Line	:	797 ROOSEVELT TRAIL WINDHAM MALL
Second Line	:
City	:	NORTH WINDHAM
State	:	ME
Zip	:	04062
Country	:	US
Telephone Number	:	207-892-8571
Fax Number	:	207-892-6297

Authorized Official
Title or Position	:	PRESIDENT AND MANAGER
Name	:	MICHAEL VAIL
Credential	:
Telephone Number	:	207-885-7454

Provider Enumeration Date	:	08/27/2006
Last Update Date	:	04/20/2018

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Directions to “HANNAFORD BROS CO LLC ” Practice Location

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