Basic Information
| Provider Information | |||||||||
| NPI: | 1609356559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NORTHUP | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 JOHNSON RD | ||||||||
| Address2: | |||||||||
| City: | GUILFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044436213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073431757 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 360 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044013900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079071000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2018 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183700000X | PI46330 | ME | Y | Pharmacy Service Providers | Pharmacy Technician |
No ID Information.