Provider Demographics
NPI:1538381413
Name:MARCACCINI, JON EUGENE (RPH)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:EUGENE
Last Name:MARCACCINI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:EVELETH
Mailing Address - State:MN
Mailing Address - Zip Code:55734-1524
Mailing Address - Country:US
Mailing Address - Phone:218-744-2774
Mailing Address - Fax:218-744-5878
Practice Address - Street 1:318 GRANT AVE
Practice Address - Street 2:
Practice Address - City:EVELETH
Practice Address - State:MN
Practice Address - Zip Code:55734-1524
Practice Address - Country:US
Practice Address - Phone:218-744-2774
Practice Address - Fax:218-744-5878
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112829183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0156740001Medicare NSC