Provider Demographics
NPI:1144396789
Name:MAST DRUG CO INC
Entity type:Organization
Organization Name:MAST DRUG CO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN MGR
Authorized Official - Prefix:
Authorized Official - First Name:POLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-438-3112
Mailing Address - Street 1:1910 ROSS MILL RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27537-8789
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 EAST BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-2731
Practice Address - Country:US
Practice Address - Phone:252-792-8216
Practice Address - Fax:252-792-7330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC56033336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD9800034Medicaid
NC7701334Medicaid
3430307OtherOTHER ID NUMBER-COMMERCIAL NUMBER
VA8507376Medicaid
NC0585158Medicaid
3430307OtherOTHER ID NUMBER-COMMERCIAL NUMBER