MEDICARE: DR. MARC J MYCKO PHARM D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PR5029	ME
2	183500000X	Pharmacist	3324	NH

General Provider Information

NPI Number	:	1588941595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARC J MYCKO PHARM D

Provider Business Mailing Address
First Line	:	128 NORWOOD FARMS RD
Second Line	:
City	:	YORK
State	:	ME
Zip	:	03909-1519
Country	:	US
Telephone Number	:	207-363-5640
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 SABATTUS ST
Second Line	:
City	:	LEWISTON
State	:	ME
Zip	:	04240-5430
Country	:	US
Telephone Number	:	207-783-2013
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2011
Last Update Date	:	11/05/2011

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