Provider Demographics
NPI:1609942366
Name:MAST DRUG CO INC
Entity Type:Organization
Organization Name:MAST DRUG CO INC
Other - Org Name:MAST PHARMACY
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 1:307 WEST BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-2145
Practice Address - Country:US
Practice Address - Phone:252-792-1015
Practice Address - Fax:252-792-2174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NC037663336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0585091Medicaid
2068431OtherPK
NC7700506Medicaid
NC7700506Medicaid