=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437161023
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J & R REXALL DRUG
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2006
-----------------------------------------------------
Last Update Date | 06/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 DOWNTOWN PLZ
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56031-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-235-9719
-----------------------------------------------------
Fax | 507-235-9696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 DOWNTOWN PLZ
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56031-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAMES MARCOVICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 507-235-9719
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 2049412
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------