Healthcare Provider Details

I. General information

NPI: 1962839514
Provider Name (Legal Business Name): THOMAS LEWIS KOTREDES RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 STATE ST
BANGOR ME
04401-5411
US

IV. Provider business mailing address

48 KNOX AVE
BANGOR ME
04401-3316
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-8369
  • Fax:
Mailing address:
  • Phone: 207-942-7187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPR3235
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: