Healthcare Provider Details

I. General information

NPI: 1295990885
Provider Name (Legal Business Name): MARCS VARIETY STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13693 LORAIN AVE
CLEVELAND OH
44111-3437
US

IV. Provider business mailing address

5841 W 130TH ST
PARMA OH
44130-9308
US

V. Phone/Fax

Practice location:
  • Phone: 216-476-6770
  • Fax: 216-476-6770
Mailing address:
  • Phone: 216-265-7700
  • Fax: 216-265-7744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number020990300
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number020990300
License Number StateOH

VIII. Authorized Official

Name: MR. DAVID FLORMAN
Title or Position: 3RD PARTY ADMINISTRATOR
Credential:
Phone: 216-265-7700