Provider Demographics
NPI:1164010229
Name:MARKETIME DRUG OF MOSCOW INC
Entity Type:Organization
Organization Name:MARKETIME DRUG OF MOSCOW INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-868-6559
Mailing Address - Street 1:872 TROY RD STE 120
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-5037
Mailing Address - Country:US
Mailing Address - Phone:208-882-7541
Mailing Address - Fax:
Practice Address - Street 1:872 TROY RD STE 120
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-5037
Practice Address - Country:US
Practice Address - Phone:208-882-7541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0023396Medicaid