Provider Demographics
NPI:1588941595
Name:MYCKO, MARC J (PHARM D)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:J
Last Name:MYCKO
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 NORWOOD FARMS RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-1519
Mailing Address - Country:US
Mailing Address - Phone:207-363-5640
Mailing Address - Fax:
Practice Address - Street 1:430 SABATTUS ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5430
Practice Address - Country:US
Practice Address - Phone:207-783-2013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-05
Last Update Date:2011-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5029183500000X
NH3324183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist