Healthcare Provider Details

I. General information

NPI: 1982980975
Provider Name (Legal Business Name): LORELLE MOLLIEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2011
Last Update Date: 10/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4547 HIAWATHA AVE C/O WALGREENS
MINNEAPOLIS MN
55406-3926
US

IV. Provider business mailing address

3345 SAINT LOUIS AVE
MINNEAPOLIS MN
55416-4394
US

V. Phone/Fax

Practice location:
  • Phone: 612-722-4249
  • Fax: 612-722-5713
Mailing address:
  • Phone: 612-722-4249
  • Fax: 612-722-5713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number119453
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: