=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871902098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENOBSCOT COMMUNITY HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2014
-----------------------------------------------------
Last Update Date | 04/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 SCHOODIC DR
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-7246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-338-6900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 439
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04402-0439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-992-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | LORI L. DWYER
-----------------------------------------------------
Credential | ESQ.
-----------------------------------------------------
Telephone | 207-992-9200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PH50001510
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH50001510
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------