Provider Demographics
NPI:1497838759
Name:LAKES SNYDER DRUG, INC
Entity Type:Organization
Organization Name:LAKES SNYDER DRUG, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:651-464-5518
Mailing Address - Street 1:808 LAKE ST S
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2614
Mailing Address - Country:US
Mailing Address - Phone:651-464-5518
Mailing Address - Fax:651-464-1513
Practice Address - Street 1:808 LAKE ST S
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2614
Practice Address - Country:US
Practice Address - Phone:651-464-5518
Practice Address - Fax:651-464-1513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261427-43336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2422107OtherNCPDP
MN1165890001Medicare NSC