Healthcare Provider Details

I. General information

NPI: 1811255318
Provider Name (Legal Business Name): SOUTH BERWICK PHARMACY SEACOAST COMPOUNDING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 MAIN ST
SOUTH BERWICK ME
03908-1543
US

IV. Provider business mailing address

289 MAIN ST
SOUTH BERWICK ME
03908-1543
US

V. Phone/Fax

Practice location:
  • Phone: 207-384-2772
  • Fax:
Mailing address:
  • Phone: 207-384-2772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH50001453
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPH50001453
License Number StateME

VIII. Authorized Official

Name: KATE KENNEY HANSEN
Title or Position: OWNER
Credential:
Phone: 207-384-2772