=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952856759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M DRUG LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2016
-----------------------------------------------------
Last Update Date | 10/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195 FORE RIVER PKWY STE 170
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04102-2782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-535-1600
-----------------------------------------------------
Fax | 207-535-1610
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1779
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04402-1779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-275-3216
-----------------------------------------------------
Fax | 207-561-4804
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PHARMACY
-----------------------------------------------------
Name | MATTHEW J MARSTON
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 207-275-3239
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH50001645
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------