Provider Demographics
NPI:1275682007
Name:LAKES AREA PHARMACY
Entity Type:Organization
Organization Name:LAKES AREA PHARMACY
Other - Org Name:LAKES AREA PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PARRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:218-568-5884
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:PEQUOT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56472-0187
Mailing Address - Country:US
Mailing Address - Phone:218-568-5884
Mailing Address - Fax:
Practice Address - Street 1:30503 STATE HWY 371
Practice Address - Street 2:
Practice Address - City:PEQUOT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56472-2913
Practice Address - Country:US
Practice Address - Phone:218-568-5884
Practice Address - Fax:218-568-8473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
MN26053773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2046127OtherPK
MN854360700Medicaid
MN854360700Medicaid