Healthcare Provider Details

I. General information

NPI: 1447430251
Provider Name (Legal Business Name): MARILYN B EKSTAM RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708A N PINE ST
ROLLA MO
65401-3138
US

IV. Provider business mailing address

606 HWY 63 S PO BOX 606
VIENNA MO
65582
US

V. Phone/Fax

Practice location:
  • Phone: 573-422-6400
  • Fax: 573-422-6403
Mailing address:
  • Phone: 573-422-6400
  • Fax: 573-422-6403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2007004488
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: