Provider Demographics
NPI:1528196219
Name:MOOSEHEAD DRUG INC.
Entity Type:Organization
Organization Name:MOOSEHEAD DRUG INC.
Other - Org Name:HARRIS DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-695-2921
Mailing Address - Street 1:PO BOX 530
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04441-0530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 PRITHAM AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:ME
Practice Address - Zip Code:04441
Practice Address - Country:US
Practice Address - Phone:207-695-2921
Practice Address - Fax:207-695-3449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MEPH500002243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2035835OtherPK
ME10288603Medicaid
922900001Medicare ID - Type Unspecified