Provider Demographics
NPI:1568759058
Name:MT BLUE DRUG INC
Entity Type:Organization
Organization Name:MT BLUE DRUG INC
Other - Org Name:MT BLUE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ PIC
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:207-474-3393
Mailing Address - Street 1:12 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-1815
Mailing Address - Country:US
Mailing Address - Phone:207-474-3393
Mailing Address - Fax:207-474-7541
Practice Address - Street 1:624 WILTON RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-6138
Practice Address - Country:US
Practice Address - Phone:207-778-5419
Practice Address - Fax:207-778-5983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-05
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MEPH500014293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131060OtherPK
ME169480000Medicaid
ME4532370002Medicare NSC