Healthcare Provider Details

I. General information

NPI: 1750003653
Provider Name (Legal Business Name): CUYUNA LAKES PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22418 STATE HWY 6 SUITE 400
CROSBY MN
56441-1645
US

IV. Provider business mailing address

320 E MAIN ST
CROSBY MN
56441-1645
US

V. Phone/Fax

Practice location:
  • Phone: 218-545-5360
  • Fax: 218-381-0020
Mailing address:
  • Phone: 218-546-2345
  • Fax: 218-546-4330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AMY LOUISE HART
Title or Position: CEO
Credential:
Phone: 218-546-2300