Provider Demographics
NPI:1679938567
Name:NYA PHARMACY LLC
Entity Type:Organization
Organization Name:NYA PHARMACY LLC
Other - Org Name:MARSDEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOEGERING
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:651-334-7322
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:NORWOOD YOUNG AMERICA
Mailing Address - State:MN
Mailing Address - Zip Code:55368-0600
Mailing Address - Country:US
Mailing Address - Phone:952-467-2100
Mailing Address - Fax:952-467-2489
Practice Address - Street 1:402 FAXON RD N
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MN
Practice Address - Zip Code:55368-9507
Practice Address - Country:US
Practice Address - Phone:952-467-2100
Practice Address - Fax:952-467-2489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MN2648713336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN561663000Medicaid
2155598OtherPK
MN561663000Medicaid