Provider Demographics
NPI:1568956415
Name:MARKS, BRIAN ELLSWORTH (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ELLSWORTH
Last Name:MARKS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 7TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:KASSON
Mailing Address - State:MN
Mailing Address - Zip Code:55944-1751
Mailing Address - Country:US
Mailing Address - Phone:320-221-0653
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0002
Practice Address - Country:US
Practice Address - Phone:507-284-2021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123736183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN123736OtherPHARMACIST LICENSE