Healthcare Provider Details

I. General information

NPI: 1568940484
Provider Name (Legal Business Name): COURTNEY RAE COLLIGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 UNION ST
BANGOR ME
04401-6160
US

IV. Provider business mailing address

226 UNION ST
BANGOR ME
04401-6160
US

V. Phone/Fax

Practice location:
  • Phone: 207-942-0515
  • Fax: 207-942-4856
Mailing address:
  • Phone: 207-942-0515
  • Fax: 207-942-4856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPR68647
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: