MEDICARE: MR. JON EUGENE MARCACCINI RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	112829	MN

General Provider Information

NPI Number	:	1538381413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JON EUGENE MARCACCINI RPH

Provider Business Mailing Address
First Line	:	318 GRANT AVE
Second Line	:
City	:	EVELETH
State	:	MN
Zip	:	55734-1524
Country	:	US
Telephone Number	:	218-744-2774
Fax Number	:	218-744-5878

Provider Business Practice Location Address
First Line	:	318 GRANT AVE
Second Line	:
City	:	EVELETH
State	:	MN
Zip	:	55734-1524
Country	:	US
Telephone Number	:	218-744-2774
Fax Number	:	218-744-5878

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	04/08/2008

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