Healthcare Provider Details

I. General information

NPI: 1275682007
Provider Name (Legal Business Name): LAKES AREA PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30503 STATE HWY 371
PEQUOT LAKES MN
56472-2913
US

IV. Provider business mailing address

PO BOX 187
PEQUOT LAKES MN
56472-0187
US

V. Phone/Fax

Practice location:
  • Phone: 218-568-5884
  • Fax: 218-568-8473
Mailing address:
  • Phone: 218-568-5884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2605377
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2046127
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 2
Identifier854360700
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer

VIII. Authorized Official

Name: DAVID PARRY
Title or Position: OWNER
Credential: RPH
Phone: 218-568-5884