Healthcare Provider Details

I. General information

NPI: 1669301339
Provider Name (Legal Business Name): MICHAEL MEDOURIS PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CVS DR
WOONSOCKET RI
02895-6195
US

IV. Provider business mailing address

139 OLDE MILL LN
NORTH KINGSTOWN RI
02852-1787
US

V. Phone/Fax

Practice location:
  • Phone: 207-232-1403
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH04747
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: