Provider Demographics
NPI:1780978841
Name:MARKETPLACE PHARMACY LLC
Entity type:Organization
Organization Name:MARKETPLACE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-381-4794
Mailing Address - Street 1:5262 KYLER AVE NE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301-4705
Mailing Address - Country:US
Mailing Address - Phone:763-497-2846
Mailing Address - Fax:763-497-0597
Practice Address - Street 1:5262 KYLER AVE NE STE 112
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301-4706
Practice Address - Country:US
Practice Address - Phone:763-497-2846
Practice Address - Fax:763-497-0597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2641433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130454OtherPK
MN906653200Medicaid