Basic Information
| Provider Information | |||||||||
| NPI: | 1568956415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARKS | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | ELLSWORTH | ||||||||
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| Credential: | PHARM.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1204 7TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | KASSON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559441751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202210653 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 1ST ST SW | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559050002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072842021 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2018 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 123736 | MN | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 123736 | 01 | MN | PHARMACIST LICENSE | OTHER |