Provider Demographics
NPI:1447430251
Name:EKSTAM, MARILYN B (RPH)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:B
Last Name:EKSTAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 HWY 63 S
Mailing Address - Street 2:PO BOX 606
Mailing Address - City:VIENNA
Mailing Address - State:MO
Mailing Address - Zip Code:65582
Mailing Address - Country:US
Mailing Address - Phone:573-422-6400
Mailing Address - Fax:573-422-6403
Practice Address - Street 1:708A N PINE ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3138
Practice Address - Country:US
Practice Address - Phone:573-422-6400
Practice Address - Fax:573-422-6403
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007004488183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist