Provider Demographics
NPI:1134224082
Name:LONGBELLA DRUG INC
Entity type:Organization
Organization Name:LONGBELLA DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANI LONGBELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:218-894-2242
Mailing Address - Street 1:653 PILLSBURY ST N
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PILLAGER
Mailing Address - State:MN
Mailing Address - Zip Code:56473-2543
Mailing Address - Country:US
Mailing Address - Phone:218-746-4321
Mailing Address - Fax:218-746-4316
Practice Address - Street 1:653 PILLSBURY ST N
Practice Address - Street 2:SUITE 2
Practice Address - City:PILLAGER
Practice Address - State:MN
Practice Address - Zip Code:56473-2543
Practice Address - Country:US
Practice Address - Phone:218-746-4321
Practice Address - Fax:218-746-4316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN26235403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN751163900Medicaid
2048467OtherPK