Provider Demographics
NPI:1225328669
Name:MOBY RX
Entity Type:Organization
Organization Name:MOBY RX
Other - Org Name:MOBY RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOMENJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDULLAYOF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-899-4600
Mailing Address - Street 1:225 WATERMAN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3634
Mailing Address - Country:US
Mailing Address - Phone:207-899-4600
Mailing Address - Fax:207-899-4613
Practice Address - Street 1:225 WATERMAN DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3634
Practice Address - Country:US
Practice Address - Phone:207-899-4600
Practice Address - Fax:207-899-4613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MEPH500014263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130568OtherPK
2130568OtherPK