Provider Demographics
NPI:1952856759
Name:M DRUG LLC
Entity Type:Organization
Organization Name:M DRUG LLC
Other - Org Name:NORTHERN LIGHT PHARMACY FORE RIVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:207-275-3239
Mailing Address - Street 1:PO BOX 1779
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1779
Mailing Address - Country:US
Mailing Address - Phone:207-275-3216
Mailing Address - Fax:207-561-4804
Practice Address - Street 1:195 FORE RIVER PKWY STE 170
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2782
Practice Address - Country:US
Practice Address - Phone:207-535-1600
Practice Address - Fax:207-535-1610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MEPH500016453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1952856759Medicaid
2164242OtherPK