Provider Demographics
NPI:1508630112
Name:LAKEWOOD HEALTH SYSTEM
Entity Type:Organization
Organization Name:LAKEWOOD HEALTH SYSTEM
Other - Org Name:LONGBELLA DRUG BY LAKEWOOD HEALTH SYSTEM - STAPLES CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:REYCRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-894-8194
Mailing Address - Street 1:49725 COUNTY 83
Mailing Address - Street 2:
Mailing Address - City:STAPLES
Mailing Address - State:MN
Mailing Address - Zip Code:56479-5280
Mailing Address - Country:US
Mailing Address - Phone:218-894-1515
Mailing Address - Fax:
Practice Address - Street 1:49725 COUNTY 83 STE 100
Practice Address - Street 2:
Practice Address - City:STAPLES
Practice Address - State:MN
Practice Address - Zip Code:56479-5280
Practice Address - Country:US
Practice Address - Phone:218-894-8761
Practice Address - Fax:218-894-8762
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKEWOOD HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN266847OtherSTATE LICENSE