Healthcare Provider Details

I. General information

NPI: 1619005493
Provider Name (Legal Business Name): INDIAN TOWNSHIP TRIBAL GOVERNMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PETER DANA POINT ROAD
PRINCETON ME
04668-0097
US

IV. Provider business mailing address

PO BOX 97 401 PETER DANA POINT ROAD
PRINCETON ME
04668-0097
US

V. Phone/Fax

Practice location:
  • Phone: 207-796-2321
  • Fax: 207-796-2422
Mailing address:
  • Phone: 207-796-2321
  • Fax: 207-796-2422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH50001209
License Number StateME

VIII. Authorized Official

Name: ANDREA M HANSON
Title or Position: COMPLIANCE SPECIALIST
Credential:
Phone: 207-796-2321