Provider Demographics
NPI:1003260969
Name:COBORNS INC
Entity Type:Organization
Organization Name:COBORNS INC
Other - Org Name:MARKETPLACE PHARMACY #2583
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:NELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:320-534-2743
Mailing Address - Street 1:PO BOX 6146
Mailing Address - Street 2:PHARMACY OFFICE
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-6146
Mailing Address - Country:US
Mailing Address - Phone:320-534-2745
Mailing Address - Fax:320-203-1095
Practice Address - Street 1:10514 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-6720
Practice Address - Country:US
Practice Address - Phone:715-634-1817
Practice Address - Fax:855-304-4787
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COBORNS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-18
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
WI9403-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159610OtherPK
WI1000056023Medicaid
0187140046Medicare NSC