Provider Demographics
NPI:1558362129
Name:LAKEVILLE SNYDER DRUG
Entity Type:Organization
Organization Name:LAKEVILLE SNYDER DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-435-3784
Mailing Address - Street 1:17665 KENWOOD TRL
Mailing Address - Street 2:LAKEVILLE SNYDER PHARMACY
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-9455
Mailing Address - Country:US
Mailing Address - Phone:952-435-3784
Mailing Address - Fax:952-435-2050
Practice Address - Street 1:17665 KENWOOD TRL
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-9455
Practice Address - Country:US
Practice Address - Phone:952-435-3784
Practice Address - Fax:952-435-2050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN260365-4333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
BL0678079OtherDEA
BL0678079OtherDEA