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General NPI Number Information
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NPI Number | 1568759058
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Entity Type | Organization
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Legal Business Name | MT BLUE DRUG INC
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Dates
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Enumeration Date | 07/05/2011
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Last Update Date | 10/03/2025
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Provider Practice Location Address
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Address Line | 624 WILTON RD
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City | FARMINGTON
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State | ME
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Zip | 04938-6138
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Country | US
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Telephone | 207-778-5419
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Fax | 207-778-5983
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Provider Business Mailing Address
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Address Line | 12 HIGH ST
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City | SKOWHEGAN
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State | ME
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Zip | 04976-1815
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Country | US
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Telephone | 207-474-3393
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Fax | 207-474-7541
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Authorized Official
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Title or Position | OWNER
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Name | KRISTY KRASNAVAGE
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Credential |
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Telephone | 207-474-3393
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH50001429
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License Number State | ME
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