Healthcare Provider Details

I. General information

NPI: 1750322186
Provider Name (Legal Business Name): LONGBELLA DRUG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 2ND AVE NE
STAPLES MN
56479-2539
US

IV. Provider business mailing address

421 2ND AVE NE
STAPLES MN
56479-2539
US

V. Phone/Fax

Practice location:
  • Phone: 218-894-2242
  • Fax: 218-894-2013
Mailing address:
  • Phone: 218-894-2242
  • Fax: 218-894-2013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2003445
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LANI LONGBELLAROBERTS
Title or Position: RPH, PRES
Credential:
Phone: 218-894-2242