Provider Demographics
NPI:1235205873
Name:MAST DRUG CO INC
Entity Type:Organization
Organization Name:MAST DRUG CO INC
Other - Org Name:MAST FAMILY DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:I
Authorized Official - Last Name:FLYE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:252-438-3112
Mailing Address - Street 1:805 S GARNETT ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536
Mailing Address - Country:US
Mailing Address - Phone:252-438-3112
Mailing Address - Fax:252-492-4096
Practice Address - Street 1:418 DABNEY DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-3944
Practice Address - Country:US
Practice Address - Phone:252-438-4158
Practice Address - Fax:252-438-7183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC017353336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0915397Medicaid
NC7700133Medicaid
2065974OtherPK
NC7700133Medicaid