MEDICARE: LAKES AREA PHARMACY

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	3336C0004X	Compounding Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy
4	3336C0003X	Community/Retail Pharmacy	2605377	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2046127	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275682007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKES AREA PHARMACY

Provider Business Mailing Address
First Line	:	PO BOX 187
Second Line	:
City	:	PEQUOT LAKES
State	:	MN
Zip	:	56472-0187
Country	:	US
Telephone Number	:	218-568-5884
Fax Number	:

Provider Business Practice Location Address
First Line	:	30503 STATE HWY 371
Second Line	:
City	:	PEQUOT LAKES
State	:	MN
Zip	:	56472-2913
Country	:	US
Telephone Number	:	218-568-5884
Fax Number	:	218-568-8473

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID PARRY
Credential	:	RPH
Telephone Number	:	218-568-5884

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	03/10/2017

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Directions to “LAKES AREA PHARMACY ” Practice Location

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