MEDICARE: THEODORE CHARLES LANDROCHE II PHARMD

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	183500000X	Pharmacist	PR5724	ME

General Provider Information

NPI Number	:	1669077715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODORE CHARLES LANDROCHE II PHARMD

Provider Business Mailing Address
First Line	:	797 ROOSEVELT TRL
Second Line	:
City	:	NORTH WINDHAM
State	:	ME
Zip	:	04062-5341
Country	:	US
Telephone Number	:	207-892-8571
Fax Number	:

Provider Business Practice Location Address
First Line	:	797 ROOSEVELT TRL
Second Line	:
City	:	NORTH WINDHAM
State	:	ME
Zip	:	04062-5341
Country	:	US
Telephone Number	:	207-892-8571
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2020
Last Update Date	:	12/04/2020

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