Provider Demographics
NPI:1376141242
Name:LEWIS, BETSY JO
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:JO
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 JUNIPER AVE
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1041
Mailing Address - Country:US
Mailing Address - Phone:218-849-6414
Mailing Address - Fax:
Practice Address - Street 1:100 JUNIPER AVE
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1041
Practice Address - Country:US
Practice Address - Phone:218-849-6414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122329183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN122329OtherLICENSE NUMBER