Healthcare Provider Details

I. General information

NPI: 1023016342
Provider Name (Legal Business Name): KETNER INVESTMENT CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 FAIR ST
NORWAY ME
04268-5628
US

IV. Provider business mailing address

54 FAIR ST
NORWAY ME
04268-5628
US

V. Phone/Fax

Practice location:
  • Phone: 207-743-8121
  • Fax: 207-744-0246
Mailing address:
  • Phone: 207-743-8121
  • Fax: 207-744-0246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH50001093
License Number StateME

VIII. Authorized Official

Name: MR. LAURENCE D KETNER
Title or Position: OWNER/PRESIDENT
Credential: RPH
Phone: 207-743-8121