=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629613005
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOTUS LTC PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2019
-----------------------------------------------------
Last Update Date | 04/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9850 51ST AVE N STE 102
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55442-3271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-415-9145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 27559
-----------------------------------------------------
City | GOLDEN VALLEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55427-0559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-425-9145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JILL MARIE LYTWYN
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 612-425-9145
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------