Healthcare Provider Details

I. General information

NPI: 1184853723
Provider Name (Legal Business Name): MLJC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2009
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 FISHERVILLE RD UNIT C
PENACOOK NH
03303
US

IV. Provider business mailing address

219 FISHERVILLE RD UNIT C
PENACOOK NH
03303
US

V. Phone/Fax

Practice location:
  • Phone: 603-565-0210
  • Fax: 603-565-0214
Mailing address:
  • Phone: 603-565-0210
  • Fax: 603-565-0214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0761
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2120912
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 2
Identifier30707542
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer

VIII. Authorized Official

Name: CHRISTINA RASLA
Title or Position: PRESIDENT
Credential:
Phone: 781-803-0976