Provider Demographics
NPI:1154671261
Name:ROLLIE, MITCHELL LEE
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:LEE
Last Name:ROLLIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 DIVISION ST S
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-2427
Mailing Address - Country:US
Mailing Address - Phone:507-645-4455
Mailing Address - Fax:507-645-6912
Practice Address - Street 1:700 DIVISION ST S
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-2427
Practice Address - Country:US
Practice Address - Phone:507-645-4455
Practice Address - Fax:507-645-6912
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-16
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121057183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist