Provider Demographics
NPI:1578372728
Name:MT BLUE DRUG INC
Entity type:Organization
Organization Name:MT BLUE DRUG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNAVAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-474-3393
Mailing Address - Street 1:624 WILTON RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-6138
Mailing Address - Country:US
Mailing Address - Phone:207-778-5419
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy