Provider Demographics
NPI:1063571446
Name:LONGBELLA DRUG INC
Entity type:Organization
Organization Name:LONGBELLA DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANI
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGBELLA ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:218-894-2242
Mailing Address - Street 1:49725 COUNTY RD 83
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STAPLES
Mailing Address - State:MN
Mailing Address - Zip Code:56479
Mailing Address - Country:US
Mailing Address - Phone:218-894-8761
Mailing Address - Fax:
Practice Address - Street 1:49725 COUNTY RD 83
Practice Address - Street 2:SUITE 100
Practice Address - City:STAPLES
Practice Address - State:MN
Practice Address - Zip Code:56479
Practice Address - Country:US
Practice Address - Phone:218-894-8761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONGBELLA DRUG INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-08
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2629273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2427917OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MN0450300003Medicare NSC