Healthcare Provider Details

I. General information

NPI: 1083277933
Provider Name (Legal Business Name): STEPHEN MAKI RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 MAIN ST
JAY ME
04239-1506
US

IV. Provider business mailing address

PO BOX 343
JAY ME
04239-0343
US

V. Phone/Fax

Practice location:
  • Phone: 207-897-9080
  • Fax: 207-897-9082
Mailing address:
  • Phone: 207-778-8969
  • Fax: 207-897-9082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPR4626
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: