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General NPI Number Information
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NPI Number | 1730292970
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Entity Type | Organization
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Legal Business Name | OLD PORT PHARMACY, INC
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Dates
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Enumeration Date | 08/15/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 195 MIDDLE ST
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City | PORTLAND
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State | ME
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Zip | 04101-4003
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Country | US
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Telephone | 207-772-2164
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Fax | 207-353-0638
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Provider Business Mailing Address
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Address Line | 195 MIDDLE ST
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City | PORTLAND
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State | ME
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Zip | 04101-4003
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Country | US
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Telephone | 207-772-2164
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Fax | 207-353-0638
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. PAUL B CHACE
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Credential | R.PH.
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Telephone | 207-240-1082
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH50001274
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License Number State | ME
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