=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558362129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKEVILLE SNYDER DRUG
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17665 KENWOOD TRL
-----------------------------------------------------
City | LAKEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55044-9455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-435-3784
-----------------------------------------------------
Fax | 952-435-2050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17665 KENWOOD TRL LAKEVILLE SNYDER PHARMACY
-----------------------------------------------------
City | LAKEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55044-9455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-435-3784
-----------------------------------------------------
Fax | 952-435-2050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. TIM J PETERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-435-3784
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 260365-4
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------