Provider Demographics
NPI:1629014014
Name:LONGBELLA DRUG INC
Entity Type:Organization
Organization Name:LONGBELLA DRUG INC
Other - Org Name:LONGBELLA DRUG MOTLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH PRES
Authorized Official - Prefix:
Authorized Official - First Name:LANI
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGBELLAROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-352-6337
Mailing Address - Street 1:1233 HIGHWAY 10 S
Mailing Address - Street 2:
Mailing Address - City:MOTLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56466-8210
Mailing Address - Country:US
Mailing Address - Phone:218-352-6337
Mailing Address - Fax:218-352-6904
Practice Address - Street 1:1233 HIGHWAY 10 S
Practice Address - Street 2:
Practice Address - City:MOTLEY
Practice Address - State:MN
Practice Address - Zip Code:56466-8210
Practice Address - Country:US
Practice Address - Phone:218-352-6337
Practice Address - Fax:218-352-6904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2615373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN028712100Medicaid
2047847OtherPK
MN028712100Medicaid