Healthcare Provider Details

I. General information

NPI: 1225328669
Provider Name (Legal Business Name): MOBY RX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 WATERMAN DR
SOUTH PORTLAND ME
04106-3634
US

IV. Provider business mailing address

225 WATERMAN DR
SOUTH PORTLAND ME
04106-3634
US

V. Phone/Fax

Practice location:
  • Phone: 207-899-4600
  • Fax: 207-899-4613
Mailing address:
  • Phone: 207-899-4600
  • Fax: 207-899-4613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH50001426
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MOMENJAN ABDULLAYOF
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 207-899-4600