Healthcare Provider Details

I. General information

NPI: 1528196219
Provider Name (Legal Business Name): MOOSEHEAD DRUG INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PRITHAM AVE
GREENVILLE ME
04441
US

IV. Provider business mailing address

PO BOX 530
GREENVILLE ME
04441-0530
US

V. Phone/Fax

Practice location:
  • Phone: 207-695-2921
  • Fax: 207-695-3449
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH50000224
License Number StateME

VIII. Authorized Official

Name: MICHAEL HARRIS
Title or Position: PHARMACY MANAGER
Credential:
Phone: 207-695-2921