Healthcare Provider Details

I. General information

NPI: 1164010229
Provider Name (Legal Business Name): MARKETIME DRUG OF MOSCOW INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

872 TROY RD STE 120
MOSCOW ID
83843-5037
US

IV. Provider business mailing address

872 TROY RD STE 120
MOSCOW ID
83843-5037
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-7541
  • Fax:
Mailing address:
  • Phone: 208-882-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ERIK JAMES NELSON
Title or Position: OWNER
Credential:
Phone: 509-868-6559